The Children Act

by Ian Mcewan

  “Not at all good.”

  He was asked to elaborate.

  Carter drew breath and looked about him, saw the parents and looked away. His patient was weak, he said, and, as expected, showing the first signs of breathlessness. If he, Carter, had had a free hand in treatment, he would have expected an eighty to ninety percent chance of a full remission. With the current course, the chances were much reduced.

  Berner asked for specific data concerning Adam’s blood.

  When the boy was admitted, Carter said, the hemoglobin count was 8.3 grams per deciliter. The norm being around 12.5. It had declined steadily. Three days ago it had been 6.4. This morning it was at 4.5. If it dropped further to 3, the situation would be extremely dangerous.

  Mark Berner was about to ask another question but Carter spoke over him.

  “The white cell count is usually somewhere between 5 and 9. It’s now 1.7. As for the platelets—”

  Fiona interrupted. “Would you kindly remind me of their function?”

  “Necessary for clotting, My Lady.”

  The norm, the consultant told the court, was 250. The boy’s count was 34. Below 20 one would expect spontaneous bleeding to occur. At this point, Mr. Carter turned his head a little away from the barrister so that he seemed to address the parents. “The latest analysis,” he said gravely, “shows us that no new blood is being produced. A healthy adolescent might be expected to produce five hundred billion blood cells a day.”

  “And if, Mr. Carter, you could transfuse?”

  “The boy would stand a decent chance. Though not as good as it would have been if we’d transfused from the start.”

  Berner paused briefly, and when he spoke again, he lowered his voice, as though to dramatize the possibility of Adam Henry overhearing him. “Have you discussed with your patient what will happen to him if he is not transfused?”

  “Only in the broadest terms. He knows he could die.”

  “He has no idea of the manner of his death. Would you care to give the court an outline?”

  “If you want.”

  Berner and Carter appeared to be colluding in the grisly facts for the benefit of the parents. It was a reasonable line of approach and Fiona did not intervene.

  Carter said slowly, “It will be distressing, not only for himself but for the medical team treating him. Some of the staff are angry. They routinely hang blood, as the Americans put it, all day long. They simply can’t understand why they should risk losing this patient. One feature of his decline will be his fight to breathe, a fight he will find frightening and is bound to lose. The sensation will be one of drowning slowly. Before that he may suffer internal bleeding. Renal failure is a possibility. Some patients lose their sight. Or he may suffer a stroke, with any number of neurological consequences. Cases differ. The only sure thing is that it would be a horrible death.”

  “Thank you, Mr. Carter.”

  Leslie Grieve for the parents rose to cross-examine. Fiona knew Grieve a little by reputation, but at that moment couldn’t recall whether he had ever appeared before her. She had seen him about the law courts—somewhat foppish, with silver, center-parted hair, high cheekbones, long thin nose, haughtily flared. There was a looseness or freedom of limb that was in agreeable contrast to the reined-in movements of his graver colleagues. The entire grand and gay effect was complicated by a problem he had with his vision, a squint of some sort, for he never appeared to be looking at what he was seeing. This disability added to his allure. It sometimes disoriented witnesses in cross-examination and it may have caused the doctor’s tetchiness now.

  Grieve said, “You accept, do you not, Mr. Carter, that the freedom of choice of medical treatment is a fundamental human right in adults?”

  “I do.”

  “And treatment without consent would constitute a trespass of the person, or indeed an assault of that person.”

  “I agree.”

  “And Adam is close to being an adult, as the law defines it in such instances.”

  Carter said, “If his eighteenth birthday was tomorrow morning, he would not yet have attained his majority today.”

  This was said with vehemence. Grieve was unruffled. “Adam is very nearly an adult. Is it not the case that he has expressed his view to treatment intelligently and articulately?”

  At this point, the consultant’s stoop vanished and he grew another inch. “His views are those of his parents. They’re not his own. His objection to being transfused is based on the doctrines of a religious cult for which he may well become a pointless martyr.”

  “Cult is a strong word, Mr. Carter,” Grieve said quietly. “Do you yourself have any religious belief?”

  “I’m an Anglican.”

  “Is the Church of England a cult?”

  Fiona looked up from her note-taking. Grieve acknowledged her by pursing his lips and pausing on a long intake of breath. The doctor looked as if he was set to leave the stand, but the barrister had not finished with him.

  “Are you aware, Mr. Carter, that the World Health Organization estimates that between fifteen and twenty percent of new AIDS cases are caused by blood transfusions?”

  “No such cases have occurred in my hospital.”

  “The hemophiliac communities of various countries have suffered the tragedy of AIDS infection on a massive scale, have they not?”

  “That was a good while ago and no longer happens.”

  “And other infections are possible via transfusion, are they not? Hepatitis, Lyme disease, malaria, syphilis, Chagas disease, graft-versus-host disease, transfusion-related lung disease. And, of course, variant CJD.”

  “All exceedingly rare.”

  “But known to occur. And then there are hemolytic reactions due to mismatched blood groups.”

  “Also rare.”

  “Really? Let me quote to you, Mr. Carter, from the highly respected Manual for Blood Conservation: ‘There are at least twenty-seven stages between taking a blood sample and the recipient receiving their transfusion and there is potential for error at each stage of the process.’ ”

  “Our staff are highly trained. They take great care. I don’t recall a single hemolytic reaction in years.”

  “If we added all these dangers up, wouldn’t you say there was enough to give a rational person pause, Mr. Carter, without that person being a member of what you call a cult?”

  “These days, blood products are tested to the highest standards.”

  “Nevertheless, it would not be wholly irrational to hesitate before accepting to be transfused.”

  Carter thought for a moment. “Hesitate, perhaps, at a stretch. But to refuse in a case like Adam’s would be irrational.”

  “You accept that hesitation is in order. So it wouldn’t be unreasonable, surely, given all the possibilities of infection and error, for the patient to insist that his consent be sought.”

  The consultant made a show of self-control. “You’re playing with words. If I’m not permitted to transfuse this patient, he may not recover. At the very least he could lose his sight.”

  Grieve said, “Isn’t there something like an ill-considered fashion in your profession for transfusion, given the risks? It’s not evidence-based, is it, Mr. Carter? It’s rather like bloodletting in the old days, except, of course, in reverse. Patients who lose a third of a pint of blood during surgery are routinely transfused, no? And yet a donor gives up a whole pint and goes straight back to work afterward, and no harm done.”

  “I can’t comment on the clinical judgment of others. The general view, I suppose, is that a patient weakened by surgery should have all the blood that God allotted.”

  “Isn’t it the case that Jehovah’s Witness patients are regularly treated now by what’s called bloodless surgery? No transfusions are necessary. Allow me to quote to you from the American Journal of Otolaryngology: ‘Bloodless surgery has come to represent good practice, and in the future it may well be the accepted standard of care.’ ”

  The cons
ultant was dismissive. “We’re not talking of surgery here. This patient needs blood because his treatment prevents him from making his own. It’s as simple as that.”

  “Thank you, Mr. Carter.”

  Grieve sat down and John Tovey, who appeared to depend on a cane with a silver head and who was counsel for Adam Henry, breathily got to his feet to cross-examine the consultant.

  “You’ve clearly spent time alone in conversation with Adam.”

  “I have.”

  “Have you formed an impression as to his intelligence?”

  “Extremely intelligent.”

  “Is he articulate?”

  “Yes.”

  “Is his judgment, his cognition, clouded by his medical condition?”

  “Not as yet.”

  “Have you suggested to him that he needs a transfusion?”

  “I have.”

  “And what has been his response?”

  “He firmly refuses it on the grounds of his religion.”

  “Are you aware of his exact age in years and months?”

  “He’s seventeen years and nine months.”

  “Thank you, Mr. Carter.”

  Berner rose to reexamine.

  “Mr. Carter, will you remind me again how long you’ve specialized in hematology?”

  “Twenty-seven years.”

  “What are the risks of an adverse reaction to a blood transfusion?”

  “Very low. Nothing compared to the certain damage that will be done in this case by failing to transfuse.”

  Berner indicated that he had nothing more to ask.

  Fiona said, “In your opinion, Mr. Carter, how much time do we have to resolve this matter?”

  “If I can’t give blood to this boy by tomorrow morning we’ll be in very dangerous territory.”

  Berner sat. Fiona thanked the doctor, who left with a curt, possibly resentful nod toward the bench. Grieve got to his feet and said he would call the father straightaway. When Mr. Henry came to the stand, he asked if he might swear on the New World Translation. The clerk told him there was only the King James. Mr. Henry nodded and swore on it, then settled his gaze patiently on Grieve.

  Kevin Henry stood around five foot six and looked as lithe and strong as a trapeze artist. He may have been adept with a mechanical digger, but he looked equally at home in his well-cut gray suit and pale green silk tie. The drift of Leslie Grieve’s questions was to draw from him a picture of early struggle, then the blossoming of a loving, stable and happy family. Who could doubt it? The Henrys had married young, at nineteen, seventeen years ago. The early years, when Kevin was employed as a laborer, were hard. He was “a bit of a wild man,” drank too much, was abusive to his wife, Naomi, though he never hit her. He was eventually sacked for being too often late for work. The rent was overdue, the baby cried through the night, the couple rowed, the neighbors complained. The Henrys were threatened with eviction from their one-bedroom flat in Streatham.

  Deliverance came in the form of two polite young men from America who doorstepped Naomi one afternoon. They came back the next day and spoke to Kevin, who was hostile at first. Finally, a visit to the nearest Kingdom Hall, a kindly welcome and then, slowly, through meeting some nice people who soon became friends, and helpful talks with wise elders of the congregation, and then Bible study, which they found hard at first—slowly, order and peace came into their lives. Kevin and Naomi began to live in the truth. They learned of the future that God had in store for mankind and they fulfilled their duty by working to spread the word. They discovered that there would be a paradise on earth and they could be a part of it by belonging to that privileged group known to the Witnesses as “other sheep.”

  They began to understand the preciousness of life. As they became better parents, their son became calmer. Kevin went on a government-sponsored course to learn how to operate heavyweight machinery. Not long after he qualified he was offered a job. On their way to Kingdom Hall with Adam to give thanks, the couple told each other they had fallen in love all over again. They held hands in the street, something they had never done before. Since that time years ago, they had lived in the truth and raised Adam in the truth within the close, supportive network of their Witness friends. Five years ago, Kevin started his own company. He owned a few diggers, dumpers and a crane and employed nine men. Now God had visited leukemia on their son and Kevin and Naomi confronted the ultimate test of faith.

  To each of the barrister’s prompting questions, Mr. Henry gave a considered reply. He was respectful, but not in awe of the court the way many people were. He spoke plainly about his early failures, seemed unembarrassed to recall the handholding moment, didn’t hesitate in this setting to use the word “love.” Frequently, he turned from Grieve’s question to address Fiona directly and held her gaze. Automatically, she tried to place his accent. A touch of cockney, a fainter trace of West Country—the confident voice of a man who took his own competence for granted, well used to giving orders. Certain British jazzmen spoke this way, a tennis coach she knew, and noncommissioned officers, senior policemen, paramedics, an oil-rig foreman who had once come before her. Not men who ran the world, but who made it run.

  Grieve paused to mark the end of this five-minute history, then asked softly, “Mr. Henry, will you tell the court why Adam is refusing a blood transfusion?”

  Mr. Henry hesitated, as if to consider the question for the first time. He turned from Grieve to direct his answer at Fiona. “You have to understand,” he said, “that blood is the essence of what’s human. It’s the soul, it’s life itself. And just as life is sacred, so is blood.” He seemed to have finished, but then he added quickly, “Blood stands for the gift of life that every living soul should be grateful for.” He delivered these sentences not as cherished beliefs but as statements of fact, like an engineer describing the construction of a bridge.

  Grieve waited, conveying by his silence that his question had not been answered. But Kevin Henry was done and looked directly ahead.

  Grieve prompted, “So, if blood’s a gift, why would your son refuse it from the doctors?”

  “Mixing your own blood with the blood of an animal or another human being is pollution, contamination. It’s a rejection of the Creator’s wonderful gift. That’s why God specifically forbids it in Genesis and Leviticus and Acts.”

  Grieve was nodding. Mr. Henry added simply, “The Bible is the word of God. Adam knows it must be obeyed.”

  “Do you and your wife love your son, Mr. Henry?”

  “Yes. We love him.” He said it quietly and looked at Fiona with defiance.

  “And if refusing a blood transfusion should cause his death?”

  Again, Kevin Henry stared ahead at the wood-paneled wall. When he spoke his voice was tight. “He’ll take his place in the kingdom of heaven on earth that’s to come.”

  “And you and your wife. How will you feel?”

  Naomi Henry still sat firmly upright, her expression behind her glasses impossible to read. She had turned to face the barrister rather than her husband in the witness stand. From where Fiona sat it was not clear if Mrs. Henry’s eyes, shrunken behind their lenses, were open.

  Kevin Henry said, “He’ll have done what is right and true, what the Lord commanded.”

  Once more, Grieve waited, then he said in a falling tone, “You’ll be grief-stricken, won’t you, Mr. Henry?”

  At this point the contrived kindness in the counsel’s tone caused the father’s voice to fail. He could only nod. Fiona saw a ripple of muscle around his throat as he regained control.

  The barrister said, “Is this refusal Adam’s decision, or is it really your own?”

  “We couldn’t turn him from it, even if we wanted to.”

  For several minutes Grieve pursued this line of questioning, looking to establish that the boy was not unduly influenced. Two elders had visited the bedside on occasion. Mr. Henry was not invited to be present. But afterward, in a hospital corridor, the elders had told him that they h
ad been impressed and moved by the boy’s grasp of his situation and his knowledge of the scriptures. They were satisfied that he knew his own mind and that he was living, as he was prepared to die, in the truth.

  Fiona sensed Berner was about to object. But he knew she would not waste time in discounting hearsay evidence.

  A final set of questions from Leslie Grieve were prompts to allow Mr. Henry to expound on the emotional maturity of his son. He did so proudly, nothing in his tone now to suggest that he thought he was about to lose him.

  It was not until three thirty that Mark Berner rose to cross-examine. He began by expressing sympathy to Mr. and Mrs. Henry for the illness of their son and hopes for a complete recovery—a sure sign, to Fiona at least, that the barrister was about to cut up rough. Kevin Henry inclined his head.

  “Just to start by clearing up a simple matter, Mr. Henry. The books of the Bible you mention, Genesis, Leviticus and Acts, forbid you to eat blood or, in one case, exhort you to abstain from it. In the New World Translation of Genesis, for example, it says, ‘Only flesh with its soul—its blood—you must not eat.’ ”

  “That’s correct.”

  “Nothing about transfusion, then.”

  Mr. Henry said patiently, “I think you’ll find that in the Greek and the Hebrew the original has the meaning of ‘take into the body.’ ”

  “Very well. But at the time of these Iron Age texts, transfusion didn’t exist. How could it be forbidden?”

  Kevin Henry shook his head. There was pity or generous tolerance in his voice. “It certainly existed in the mind of God. You need to understand that these books are his word. He inspired his chosen prophets to write down his will. It doesn’t matter what age it was, Stone, Bronze or whatever.”

  “That may well be, Mr. Henry. But many Jehovah’s Witnesses query this idea about transfusion on exactly these terms. They’re prepared to accept blood products, or certain blood products, without rejecting their faith. Isn’t it the case that other options are open to young Adam and you could play your part in persuading him to take them and save his life?”