One element of Esther’s prognosis is the expectation that she will die in childhood. An obvious implication is that she has a reduced amount of well-being to look forward to. However, the amount of well-being in a life is not likely to be evenly distributed across a lifespan. Some periods may have more well-being; others may have less. There may even be periods (taken alone) that have negative net well-being.
What is the prudential value of the first phase of life?
Before answering that question, we should separate out the value of life from the disvalue of death. On one plausible view, death is bad for us at least in part because it deprives us of future well-being. Premature death is particularly bad because of the shortened length of future life and because of the amount of positive well-being that is thereby lost. Yet our focus here is different. We are assessing how good it would be to live, not how bad it would be to die. When we are thinking about the value of a life, the absence of a period of positive well-being (a year of happiness, say) represents a reduction in what we have to consider on the plus side of the scales of well-being. It does not itself constitute a negative, as that would double-count the loss.
We could consider first the very shortest of lives. Imagine that you had been stillborn in late gestation or during the birth process. Would you have had a life worth living? Would it have been better for you to have never been conceived?
Potentially, life in utero has no prudential value—either positive or negative. In terms of subjective well-being, there are difficult questions about whether and when foetuses are capable of experiencing pain. However, foetuses are not likely to be cold or hungry, and in the normal course of in utero development, there would not be any aversive stimuli likely to cause pain. There are similar epistemic problems in knowing what positive experiences foetuses may have. They may experience warmth and physical containment, but would lack most of the stimuli that appear to soothe the ex utero infant, such as feeding, holding, caressing, and comforting.
Does foetal life contain any objective value?
As with most questions related to objective elements of well-being, the answer to that question will depend on which particular set of objective values are included. However, most lists include components that are dependent on consciousness. On such theories, many, if not all, elements of well-being might be assumed to be absent during foetal life.
One possibility is that foetal life is something like a sleep state. It might be thought that sleep, as a period of unconsciousness, has zero contemporaneous contribution to well-being, but rather gains its value upon waking due to the instrumental value of a state of rest as well as the retrospective appreciation that one might feel for having slept. Foetal life may similarly gain its value once the foetus is born. But, ultimately, it is difficult to reach any confident conclusions about the prudential value of foetal life.
What of an infant who dies early?
Consider, for example, an otherwise normal infant who dies from sudden infant death syndrome at six weeks of age. What is the value of that short life for such an individual?
On one view, very short lives might be intrinsically bad. For example, David Benatar argues that even full-length human lives are frequently bad . He cites the negative mental states, preference frustration, and lack of objective value that characterise almost all human life. Benatar’s view might appear extremely pessimistic, and many do not share it. Nevertheless, even if one is not inclined to accept the radical conclusion that there is negative net well-being in a full-length human life, some of Benatar’s insights might be relevant to an assessment of very short lives. Benatar lists some of the common negative hedonic states that afflict all of us on a daily basis: ‘hunger, thirst, bowel and bladder distension (as these organs become filled), tiredness, stress, thermal discomfort (that is, feeling either too hot or too cold), and itch’. He suggests that significant portions of each day are marked by one or another of these states and that their pervasiveness is often underestimated. Relief from these states sometimes leads to physical pleasure—such as pleasure from eating or the transient positive sensation from scratching an itch—but more commonly simply returns us to a neutral (or preexisting) hedonic state.
These common negative sensations certainly affect infants. However, as parents of newborns will freely attest, the ever-present challenge is in knowing what kind of sensation is present at any particular moment. Is the infant crying because she is still hungry or, perhaps, because she has overeaten and is experiencing gastroesophageal reflux? Is she uncomfortable and in need of soothing, or is she tired and in need of sleep? The challenge for parents, especially new parents, is that it can be extremely difficult to distinguish between different causes or types of distress. What is more, the distress of newborn infants is often intense and protracted. From one to three months of age, infants reportedly cry an average of two hours per day, with some infants experiencing considerably longer periods of crying, particularly around the four to six week mark; and ‘unsettled’ infants referred to health professionals have been reported to cry for more than five hours per day. No one can know the subjective experience of an infant. Crying behaviour obviously has an important functional and evolutionary role, and it is possible that at least some infant crying is not indicative of a strongly negative mental state. Yet it would be a mistake to discount infant crying for that reason. The external evidence indicates a state of intense anguish. There may not be a parallel mental state, but such intense manifestations in an older person would usually be seen only in the presence of severe physical or mental pain. One should be very loath to ignore that evidence, while also acknowledging that it is difficult to know just how bad the corresponding states are.
An important and related question is whether states of distress in infants have an affective dimension that is equivalent to states of distress in older children or adults. Philosophical and scientific studies of pain have often distinguished between sensory and affective dimensions. It has long been thought that much of the badness of pain is its affective element—this is, the quality of the pain experience that leads us to seek to avoid it. If the affective element of infant pain (or distress) were diminished or absent, then the negative value of pain in infancy would be considerably less than that of similar states later in life. There are two ways of responding to this claim. The first is to emphasise the fundamental difficulty of assessing the affective dimension of a subject’s experience when the subject is unable to report it. One simply cannot know what pain or distress is like for an infant, and one’s assessments are liable to be influenced by one’s own empathy for the infant. The second is to note that functional neuroimaging studies of infants experiencing painful stimuli indicate patterns of activation that are very similar to those seen in adults. This may imply that the affective dimension of painful experience (and the unpleasantness) in infants is also similar to that in adults.
Are there correlative positives or pleasures in the lives of newborns?
Here, too, their developmental stage makes it difficult to be certain. Newborns certainly experience relief from negative sensations, and they also appear to appreciate some simple pleasures—for example, from physical touch and the sensation of being held or carried or from visual, olfactory, and auditory signs of the proximity of their mother. Outward signs of pleasure are limited in very young infants (smiling typically emerges at six weeks of age). Of course, a lack of positive cues does not mean a lack of positive experiences. However, it is hard to identify any positive experiences in newborns that are as intense as the corresponding periods of negative well-being.
What of other theories of well-being?
Preference- or desire-based accounts do not offer a straightforward way of evaluating newborn life. Newborns clearly have some preferences, such as relief from the negative physical sensations described above, as well as desires for attention and the proximity of parents. Yet it is difficult to make any meaningful assessment of the degree to which an infant’s preferences are satisfied or frustrated. Do objective list theories fare any better? Many of the elements that are often listed as being objectively valuable for human life are not ones that are accessible or available to the infant. One element, development of deep interpersonal relationships, is clearly present for most newborns. Indeed, the intensity of the parent–infant bond developed at this stage might mean that this value is highly relevant, and positive, for the infant. Yet it is harder to identify other objective values that might apply.
While there are certainly some positives in the lives of newborns, arguably the principal value of life lies ahead of the infant. This value arises both from an infant’s future subjective experience and from the realization of future objectively valuable elements of well-being, such as agency, understanding, enjoyment, learning, and the development of broader interpersonal relationships.
It is not clear how to weigh up the overall well-being of infant life. Perhaps the negative physical sensations and distress must simply be endured for the sake of the positive well-being to come (certainly, some parents entertain this sort of sentiment during the initial exhausting period of caring for a newborn). Or perhaps the value of the physical consolations and developing parent–infant bond outweighs the periods of crying and distress. There are no easy answers.
Given the discussion above, how should one approach the case at hand?
Personally, we are agnostic about the overall prudential value of life for an otherwise healthy infant who dies suddenly at six weeks of age. Nevertheless, we contend that the value is at best mildly positive. It seems implausible to us that the life of such an infant would be strongly positive for her. This intuition is important because if there is reason to believe that an infant who will have a short life will suffer more than average, then there may be reason to think that her short life would not be worth living. If, for example, it is known that Esther will die at six weeks of age, there is a strong case to be made that surgery would not be in her best interests. Of course, this will depend on how much suffering Esther would experience as a consequence of the surgery. If she had perfect analgesia, such that she would experience no pain from surgery, that argument may not pertain. (We return below to the problem of perfect analgesia and reasons why it may not be achieved.)
Though a more in-depth discussion is beyond the scope of this paper, in our view, the outcome that has the most reason to render a life not worth living is not survival with long-term disability, but death after a prolonged period in intensive care. An extremely premature infant who dies after a tumultuous four-month period in neonatal intensive care has unquestionably experienced negative net well-being. The infant will have experienced little in the way of positives, and it does not seem conceivable that those positives would outweigh the negatives. It may have been reasonable to embark on provision of neonatal intensive care because of the infant’s uncertain outcome and the possibility that the infant might survive to enjoy a life worth living. However, if it were known in advance that death was the certain outcome, we suggest that it would have unquestionably been unethical to initiate life-sustaining therapy.
If we are right that very early human life contains relatively less overall well-being, how long does this extend?
Is it confined to the first months of life, or does it stretch to the second year of life or later? We are going to have to set aside such questions for this paper. Suffice it to say that early life contains fewer elements of well-being than later life in large part because of the developmental stage of newborns and infants. This relation between developmental stage and reduced well-being may be particularly relevant when considering individuals whose long-term capacities will never advance beyond those of an infant.
Source – Wilkinson, D., Zayegh, A. Valuing life and evaluating suffering in infants with life-limiting illness. Theor Med Bioeth (2020)