When medicine moves faster than morality

You may recall the article of September 4th, with justifiable pride, outlining the stellar achievements of Ballina native Dr Patrick McNamara as one of the world's leading neonatologists, a pioneer in the field of neonatal hemodynamics in premature infants. The article deservedly focused on the medical wonder, so I ignored some pressing questions that loomed like an elephant in the beautifully ordered intensive care unit.

But at a recent family gathering, the unspoken was posited. Did I consider mentioning 'it' or had 'it' crossed my mind. 'It' was indeed on my mind, but since it is a question rife with moral and philosophical quandaries, I chose not to detract from the uplifting nature of the story. Now, perhaps, 'it' deserves scrutiny.

There is an apparent, almost seismic fracture in modern medicine, one stream dedicated to saving lives at the earliest possible gestation, another actively destroying embryos up to full-term pregnancies. Reduced to its most fundamental elements, viability would appear to be based on a single criterion, whether the child is wanted or not. However, that may be too shallow an interpretation, and so I must delve further.

Six months after Nash Keen's unprecedented survival made headlines around the world, the ripple effects of his tiny existence continue to reshape debates far beyond the neonatal intensive care unit where he spent his first six months of life. What started as a purely medical story about pushing the boundaries of human survival has evolved into something far more complex: a collision between scientific possibility and moral certainty, leaving lawmakers, ethicists, and ordinary people grappling with questions that nobody quite knows how to answer.

The uncomfortable truth about Nash's story is that it has forced us to confront the arbitrary nature of the lines we draw around life and death. When the US Supreme Court established the legal framework for abortion in Roe v. Wade back in 1973, it pegged viability at around 28 weeks - about 2.2 pounds. 

It seemed reasonable enough at the time. Medical students were being scolded for attempting to resuscitate babies under 1,000 grams. The line felt solid, scientific, immutable.

Except lines have a habit of moving when nobody's looking. Today, we have babies surviving at 300 grams, roughly the weight of a decent smartphone. Nash weighed less than a tin of baked beans when he drew his first breath, yet here he is, toddling about with that particular brand of toddler mischief that suggests a perfectly normal future ahead of him.

The anti-abortion lobby has seized upon cases like Nash's with evangelical fervour. Here, they argue, is proof positive that the notion of viability is becoming obsolete. If a fetus can survive at 21 weeks, what's the moral difference between that and 20 weeks? Or 19? It's a fair question, for anyone grappling with the genuine complexities involved.

However, the reality is more complex than the soundbites suggest. Babies surviving at these extreme margins need extraordinary interventions - artificial ventilation, round-the-clock monitoring, surgeries that would challenge adult patients. The financial cost runs into hundreds of thousands. The emotional toll on families can be devastating. Many survivors face lifelong consequences: cerebral palsy, blindness, and developmental delays. These aren't details the campaigners like to dwell on, but they're essential to understanding what we're actually talking about when we discuss 'viability'.

What makes this particularly thorny is the fundamental disconnect between the medical and political spheres. The doctors saving babies like Nash - people like Patrick McNamara and his colleagues in Iowa - find themselves inadvertently thrust into culture wars they never wanted to join. Their motivation is straightforward: parents desperately want their babies to survive, and advancing medical technology makes that increasingly possible. It's got nothing to do with abortion politics, everything to do with human hope colliding with scientific possibility.

The team at Iowa would see their work as completely divorced from political realities. It's an understandable position, but almost impossible to maintain. When your medical advances are being weaponised in legislative chambers and courtrooms, claiming political neutrality becomes increasingly difficult.

The philosophical implications are genuinely mind-bending. Current abortion law assumes that a woman's right to end her pregnancy necessarily involves terminating the fetus. But what happens when those two things can be separated? Scientists in Philadelphia and the Netherlands are developing artificial wombs - known as 'biobags' - that could theoretically gestate extremely premature babies outside the human body. The Dutch researchers suggest their prototype could be ready for human use by 2029.

Imagine a world where unwanted pregnancies could be ended by transferring the fetus to an artificial womb rather than terminating it. Suddenly, the right not to be pregnant becomes distinct from the right to prevent the creation of a new person. It's the sort of scenario that makes bioethicists reach for strong drink and politicians pretend they haven't heard the question.

Katie Watson, a bioethicist at Northwestern University, calls this an 'Orwellian scenario'. Picture this dystopian tableau: medics with their artificial wombs in tow, ready to extract unwanted pregnancies. It's the sort of nightmare scenario that would have had Orwell binning his typewriter and taking up landscape painting instead.

The practicalities alone are enough to give you a headache. Does the medical establishment suddenly find itself running a vast network of artificial nurseries? Do we create a foster care system for test-tube gestations? And what exactly happens to the fundamental principle that a woman gets to decide what happens inside her own body when that body becomes just one option among several for growing babies?

Christopher Kaczor, who teaches philosophy at Loyola Marymount, believes artificial wombs might allow the whole abortion argument to disappear in a puff of technological smoke. His thesis is seductively simple: disconnect pregnancy from foetal development, and suddenly everyone's happy. A woman can escape an unwanted pregnancy while the foetus gets its shot at life in a mechanical incubator.

The medical establishment, confronted with these shifting moral sands, has retreated into that particularly maddening form of institutional denial that manages to irritate absolutely everyone. The American College of Obstetricians and Gynaecologists now insists that viability occurs somewhere between 20 and 25 weeks - a spread so generous it could accommodate a small war - while muttering piously about "ethically challenging decisions" without actually making any. Rather like asking your GP what's wrong with you and being told it's definitely a medical condition that will require some sort of treatment at some point in the future. It's the institutional equivalent of a shrug.

American hospitals are making individual decisions, some choosing not to provide intensive care to babies born before 23 or 24 weeks, arguing it's unethical to subject families to such interventions when outcomes remain uncertain. McNamara's team in Iowa will continue pushing the boundaries precisely because they've demonstrated that survival is possible with the proper skill set.

This unevenness in standardisation inevitably results in a level of care that varies depending on location and institutional philosophy. Today, a baby born at 22 weeks in one hospital in the United States might receive an intensive intervention, while the same baby born across the state might receive only palliative measures. It's an arbitrary system that depends more on postal codes than principled medical decision-making.

What's perhaps most striking about Nash's story is how it highlights the gap between medical possibility and social readiness to confront the implications. We've become extraordinarily good at keeping extremely premature babies alive, but we haven't figured out what that means for how we think about the beginning of life, parental rights, or the proper limits of medical intervention.

The Supreme Court justices who cobbled together Roe back in 1973 were clever enough to spot this particular elephant lumbering toward the maternity ward. They crafted their decision with deliberate vagueness, using flexible language that could adapt to any future medical advances, nor were they philosophers trying to pin down the exact moment of 'ensoulment'. Theologians may wrestle with the mysteries of divine creation, but these were pragmatic lawyers doing what pragmatic lawyers do: cobbling together a legal compromise that might actually survive contact with the real world.

Their genius lay in recognising that the question of when life begins was entirely beyond their pay grade. Instead, they focused on the rather more manageable task of creating a framework that could balance a woman's demand to control her own body against the state's interest in potential life, without getting bogged down in metaphysical debates that had been stumping humanity since we first worked out where babies come from.

The trouble with tidy legal frameworks is that they have an unfortunate tendency to crumble the moment real life comes knocking. Nash Keen and his fellow micro-survivors have done what inconvenient facts always do to comfortable assumptions - blown them to smithereens. 

We're now faced with the sort of questions we've spent decades cheerfully pretending didn't exist.

When exactly does life begin? What do we owe to extremely premature infants? How do we balance medical possibility against quality of life? And what happens - here's the really head-spinning bit - when science reaches the point where you can grow babies entirely outside women, like some sort of high-tech farm for humans?

These are no longer abstract philosophical parlour games. They're urgent, practical questions demanding answers from people who'd much rather be getting on with their jobs than rewriting the moral rulebook of Western civilisation.

These aren't questions with easy answers, which is precisely why they make people so uncomfortable. Nash Keen, meanwhile, toddles about his Iowa home utterly oblivious to the fact that his mere existence has sent ethicists diving for cover and politicians scrambling for new soundbites.

His existence is proof that the boundaries between what is possible and what is impossible are more porous than we imagined. How you choose to interpret this depends mainly on which side of the political and theological fence you've pitched your tent.