David Archard

Prolonging neonatal lifeThe paradox that medicine’s success breeds medicine’s problems is well known to readers of the Journal of Medical Ethics. Advances in neonatal medicine have worked wonders. Not long ago, extremely premature birth babies, or those born with very serious health problems, would inevitably have died. Today, neonatologists can resuscitate babies born at ever-earlier stages of gestation. And very ill babies also benefit from advances in neonatal intensive care. Infant lives can be prolonged. Unfortunately, several such babies will not survive for long whatever is done for them. Others will live to leave hospital, but face severe health problems. Doctors have gained the ability to prolong neonatal life. But should they always do so? This question is central to the recent report of the Nuffield Council on Bioethics, Critical care decisions in fetal and neonatal medicine.1 In many quarters, the report received a very positive response, commended in The Lancet as “thoughtful, sensitive and sensible” and welcomed by the premature baby charity BLISS. Critics attacked on both flanks. The report goes too far—ushering in a culture of “throw away babies”. Or it does not go far enough—failing to endorse the Dutch precedent to sanction active neonatal euthanasia.TOO FAR?One of the key recommendations of the report is that guidelines be developed in relation to the institution of intensive neonatal care. It is these guidelines, which have been savaged by some parts of the media. The BMA called them “blanket rules” smothering clinical discretion. The guidelines on resuscitation at birth apply to babies born at the borderline of viability, that is, at or before a gestational age of 25 weeks 6 days. The earlier the baby is born, the lower are the chances that he/she will survive to leave hospital. Before 21 weeks 6 days, none of …

For many contemporary liberal political philosophers the appropriate response to the facts of pluralism is the requirement of public reasonableness, namely that individuals should be able to offer to their fellow citizens reasons for their political actions that can generally be accepted.This article finds wanting two possible arguments for such a requirement: one from a liberal principle of legitimacy and the other from a natural duty of political civility. A respect in which conversational restraint in the face of political agreement involves incivility is sketched.The proceduralist view which commends substantive disagreement within agreement on procedures is briefly outlined, as is the possible role for civic virtue on this view.

This article examines what is wrong with some expressive acts, ‘insults’. Their putative wrongfulness is distinguished from the causing of indirect harms, aggregated harms, contextual harms, and damaging misrepresentations. The article clarifies what insults are, making use of work by Neu and Austin, and argues that their wrongfulness cannot lie in the hurt that is caused to those at whom such acts are directed. Rather it must lie in what they seek to do, namely to denigrate the other. The causing of offence is at most evidence that an insult has been communicated; it is not independent grounds of proscription or constraint. The victim of an insult may know that she has been insulted but not accept or agree with the insult, and thereby submit to the insulter. Hence insults need not, as Waldron argues they do, occasion dignitary harms. They do not of themselves subvert their victims' equal moral status. The claim that hateful speech endorses inequality should not be conflated with a claim that such speech directly subverts equality. Thus, ‘wounding words’ should not unduly trouble the liberal defender of free speech either on the grounds of preventing offence or on those of avoiding dignitary harms.