On April 28, 2018, twenty-three-month-old Alfie Evans died while being held at Alder Hey Children's Hospital, five days after his ventilator had been removed. Alfie had first been admitted to the hospital in December 2016, where he had received treatment for an undiagnosed neurodegenerative disorder until medical staff determined it was in his "best interests" to withdraw medical care, and, for a time, even basic nutrition and hydration.
The furor following this decision has been well documented. The world watched in dismay as Alfie's parents fought the British court and health systems that they believed had wrongly condemned their son to death.
Protests by "Alfie's Army" were organized in cities across the globe, air ambulances from Germany and Italy were dispatched to take Alfie to hospitals outside of the United Kingdom, and Pope Francis personally urged Alder Hey to allow Alfie to seek treatment elsewhere. Italy went so far as to as to grant citizenship to Alfie in the hope that it would allow for "an immediate transfer." Alfie had reportedly been able to breathe on his own for far longer than the hospital predicted, leading to heartbreaking accounts of his father attempting to provide him with mouth-to-mouth resuscitation. The horror over Alfie's story was compounded by the similar recent case of Charlie Gard, an infant with a neurodegenerative disorder who died after being taken off life support and forcibly held at a different U.K. hospital in direct opposition to his parent's wishes. Charlie's parents' requests to take him to the United States for further treatment were repeatedly denied. In both cases, the parents were not permitted to even take their children home.
Yet despite international outrage, and the forceful legal and moral arguments mounted in favor of allowing Alfie's parents to guide his care, the courts and hospitals that assumed control over Alfie's fate appeared entirely unmoved. This has led to a series of heated, ongoing debates over what guided the hospitals' reasoning, and how they benefited from not permitting Charlie or Alfie to leave.
Some have attributed this intransigence to simple arrogance. Having determined the "best course of treatment" for Alfie, British medical experts refused to consider that he might be better cared for elsewhere, and the courts merely backed them up. Others have argued that it reflects England's entrenched class hierarchy, as Alfie's parents, Tom Evans and Kate James, appeared to be a working-class couple facing off against the ruling elite. Still others have claimed that the conflict contained a religious component: Tom travelled to Rome to invoke the assistance of Pope Francis, who gave him a compassionate welcome, while the Archbishop of Liverpool sided with the U.K. establishment. Further, the Italian priest who had been ministering to the Evans family was ordered to leave the hospital.
These possible underlying motives aside, the hospital's actions seem to be in line with the utilitarian ethics of Peter Singer, the Australian philosopher who has argued that the value of human life is not inherent, but rather based on external factors such as health, intelligence, rational self-consciousness, and quality of life. In the 1993 edition of Practical Ethics, Singer devoted a chapter to discussing the taking of human life. He concluded that "killing a disabled infant is not morally equivalent to killing a person. Very often it is not wrong at all."
This way of thinking may have influenced the decisions made for Alfie. In a revealing report, Life News notes that High Court Justice Anthony Hayden interrupted Tom Evans's attorney shortly after he pointed out that Alfie had been breathing independently for nineteen hours, suggesting that his condition was not as dire as had been previously thought. The attorney, Paul Diamond, began to say, "We do have a human being - " at which point the judge cut him off, stating, "I don't need to be reminded we have a human being. You do not have the moral high ground in this court." He also criticized Diamond for using "emotive terms" when Diamond appealed to "common humanity and common sense." Hayden later rejected his application, asserting that "there is virtually nothing of [Alfie's] brain left."
Yet even Singer took the feelings of parents into consideration when formulating his arguments regarding disabled infants:
When the life of an infant will be so miserable as not to be worth living, from the internal perspective of the being who will lead that life . . . if there are no "extrinsic" reasons for keeping the infant alive - like the feelings of the parents - it is better that the child should be helped to die without further suffering.
The decision of the hospitals and courts to disregard not only the feelings of the parents in this case but also the efforts of foreign medical authorities to take responsibility for Alfie is confounding. To Singer, the pain or comfort of parents and the burden on a state's medical resources are both important factors in determining the fate, or "best interests," of disabled children. Particularly since Alder Hey's medical staff admitted that they had not arrived at a diagnosis for Alfie, it is difficult to understand what lay at the heart of their decision to prevent his travel to Rome, and what they believed they stood to gain.
A clue to their motives, however, might be found in the famous challenge of King Solomon to two mothers who appeared before his court. The women had lived in the same house and had given birth within days of one another, yet one of their babies had tragically died. Each claimed that her healthy, living baby had been kidnapped by the other woman and replaced with the dead infant. To resolve the matter, Solomon ordered his servants to fetch a sword and to "divide the living child in two, and give half to one, and half to the other." The true mother pleaded for her son to be given to her rival, as long as he might be allowed to live, while the mother of the deceased child agreed with the verdict, stating, "Let it be neither mine nor yours, divide it." Solomon immediately ordered that the child be given to the woman who had begged for his life.
This episode in 1 Kings: 3 concludes with "all of Israel [hearing] the judgment" and seeing "that the wisdom of G-d" resided with the king. The people were awed by Solomon. Today, his bold, incisive judgment is so familiar that its reasoning may seem obvious. But it is worthwhile to consider how Solomon's order might be taken in a world of sophisticated ethicists and powerful administrators.
The "false mother" in Solomon's court did not appear to care whether the child in question lived or died. Her motivations may seem alien; did she simply wish to see another mother suffer as she had? Or was she solely focused on "winning" and being proven right? Did she want power over the child? To save face? Or was she simply terrified of the king? It is not at all clear how she stood to benefit from embracing Solomon's initial ruling. The true mother is far easier to relate to; one would assume that no decent person would wish to see a child killed simply to satisfy a dispute. At the very least, only one woman can be said to have had the "best interests" of the child in mind.
Solomon's ruling is often cited as a demonstration of the dangers of flawed moderation, the idea that something that seems superficially fair or reasonable can mask a greater evil. Notably, only the true mother's "compassion was aroused for her son," when she pleaded for him to be given to the other woman in exchange for his life. The text does not discuss the risk involved in challenging a king's judgment, but one can imagine it would have been considerable. No mention is made of the other woman experiencing any emotion whatsoever.
The contrast between their reactions has immediately recognizable parallels in the case of Alfie. His heartbroken parents fought against and were impassively observed by practical, resigned administrators and court officials.
In one of the many rulings concerning Alfie, High Court Justice Anthony Hayden praised Alfie's father extensively but condescendingly, prompting criticisms regarding the elitism that seemed inherent in the proceedings. After commending Evans's thorough understanding of the medical issues involved, he wrote,
[Evans] left school at 16. He served an apprenticeship as a plasterer. It says much about his commitment to his son and the time and energy he has directed to this case that he has absorbed the issues so completely and intelligently. He believes passionately that his view of Alfie's future is the correct one . . .
[Evans's] case is not entirely easy to state. His core dilemma, from which he struggles to escape, is that whilst he recognises and understands fully that the weight of the evidence spells out the futility of Alfie's situation he is, as a father, unable to relinquish hope. This is to my mind entirely understandable. It is a facet of [his] grief . . .
I have formed the view that [he] understands entirely what the significance of these [medical] scans is. Time and again in his evidence he avoided confronting them. Though conscious of repeating myself here I do wish to stress again that I entirely understand [his] dilemma.
Despite his acknowledgment of Evans's comprehension of the facts, Hayden denied even his request "that Alfie should be allowed home to die 'when he decides to.'" Notably, Hayden framed the father's "dilemma, from which he struggles to escape" as being a self-induced psychological state, rather than one created by the government's actions.
A document released by Alder Hey that addressed "frequently asked questions" struck a cooler tone:
We will always seek to reach agreement with parents of the child concerned. However in Alfie's case we are in the very unusual situation where agreement has not been reached following many discussions and mediation meetings . . .
The views of the parents will be very important in reaching a decision on 'best interests' but they do not give the parent an absolute right. Decisions relating to medical treatment in children have been taken on this basis for many years. In Alfie's case, his parents tried to challenge that approach in their appeal from the decision of Mr Justice Hayden.
They also insisted that they had "fully cooperated" with specialists in Rome who were willing to treat Alfie, and had arrived at a "unanimous agreement" that all such efforts would be futile. But the Rome-based Bambino Gesu pediatric hospital had publicly offered life-sustaining care - along with the possibility of surgery to enhance his breathing and conducting further tests to arrive at a diagnosis.
In the story of Solomon, the woman who had kidnapped a child arguably had nothing left to lose by allowing another woman's son to die. She had already lost a child. At least in this way, she would be able to maintain her pride and not be proven a liar. The case of Alfie Evans and Alder Hey may not be so different. The public challenge to their judgment, and Alfie's subsequent independent breathing, might have embarrassed them. Their thinly veiled annoyance at the parents' presumption suggests that this is a rare and bold move. By not allowing him to leave, they might have believed they would be spared further humiliation and bureaucratic upheaval.
Like King Solomon, the courts in England were presented with a straightforward question: To whom does this child belong? To Solomon, the true parent was unquestionably the one willing to sacrifice for the child, to safeguard his life even at the expense of never seeing him again. This clarity may seem facile in a time of uncertain bioethics and questions regarding what it means to be alive. And yet, as Solomon also wrote, "What has been is what will be, and what has been done is what will be done, and there is nothing new under the sun."