‘The Children Act’ by Ian McEwan (Vintage, 2014)

71s7+3ucHHLA number of Ian McEwan’s previous novels have touched upon issues surrounding medicine and medical ethics, such as euthanasia in Amsterdam (1998) or the life of a successful neurosurgeon and the representation of Huntington’s disease in Saturday (2005). His most recent novel, The Children Act (2014), is about the conflict between religious conducts, personal autonomy, and the welfare of a child. It follows Fiona Maye, a High Court judge who presides over cases in the family court, as she hears the case of a seventeen-year-old Jehovah’s Witness, Adam Henry, whose family refuses a critical blood transfusion on religious grounds. Fiona is in the difficult position of having to mediate between the family’s religious conducts on one hand, and the doctors’ duty to save Adam’s life on the other.

The plot is a five-part courtroom drama. The first section shows that Fiona leads an affluent, middle-class lifestyle by virtue of her legal career, albeit with a predominant sense of woe at her childlessness. Her life is disrupted by the sudden breakdown of her marriage. In the second part of the novel, she hears Adam’s case, then in the third part goes to visit him personally in the hospital and subsequently delivers her verdict and, in the last two parts, faces the denouement of the events that she has set in motion.

The trappings of middle-class affluence that the novel establishes in the opening – like the luxurious flat, replica Renoir lithograph, Fiona’s cultivated interest in high art, music and literature, et cetera – seem to situate the novel within a very narrow section of society.  This is further compounded by the fact that most of the characters in the novel are members of the legal profession who seem sequestered from the people on whose behalf they act. There is a predominant sense throughout the novel that it is only the wealthy, middle-class judges or lawyers who participate within the ethical or legal debates. Because of the novel’s inward-looking, bourgeois perspective, the political agenda that it purports, of critiquing extreme positions of faith that deny people certain rights, is rendered as the conceit of an educated, affluent elite rather than a moral or political debate that engages all of society.

The case that Fiona is presented with is complex. Adam is suffering from leukaemia. The regular course of treatment would require him to be administered a blood transfusion, which he and his parents refuse as they consider it prohibited by Levitical law. As a result, the hospital can either withhold full treatment, or continue to treat him but withhold transfusion. In either case, it is highly likely that Adam would die a slow and painful death. Adam himself is quite mature and articulate, and he seems to be aware of the consequences of this decision. He is only three months shy of full majority, at which point he would be legally entitled to refuse the transfusion.

Fiona is confronted by a number of difficult problems: one is the nature of welfare itself, and whether it would be in Adam’s best interest to transfuse him against his will or to acknowledge his autonomy and allow him the right to refuse transfusion, despite the pressing need for it during his treatment. The second question is that of religious freedom, and the degree to which Fiona balances Adam’s welfare against his faith. There is also the question of whether Adam chose to uphold these religious obligations voluntarily, or whether they are a result of him never having been aware of an alternative way of life outside of his religious community. Another issue is the nature of consent, as the hospital’s case to overrule his refusal rests on a seemingly-arbitrary technicality that Adam is only a few months shy of his eighteenth birthday.

The medico-ethical and jurisprudential issues that this novel raises are of particular interest within the medical humanities as they explore the tension between the duty of the medical institutions and of the state to save lives on one hand and certain religious conducts and an individual’s freedom to abide by them on the other. These conflicting positions are explored on the level of the law and the judiciary, and whether or not there is space within the legal frameworks in place that allow doctors and hospitals to save lives for religious beliefs that are central to the lives of the patients. Cases concerning Jehovah’s Witness parents who refused blood transfusions for their children are quite frequent in the High Court. McEwan notes, in his column for The Guardian ‘The law versus religious belief’, that he drew upon a real case in the High Court that was presided over by Sir Alan Ward. The plot of The Children Act follows this case quite consistently. Similarly, a Press Association report in The Guardian (December 8, 2014), a few months after this novel was published, describes how Mr Justice Moylan ruled in another similar case that the child’s best interest was to be transfused in spite of the ‘deeply held views’ of his parents. This proposition that the child’s best interest is opposed to the parents’ religious views supposes that the relationship between faith and welfare to be conflicting. The principles that are fundamental to religious minorities seem to be excluded from these considerations of welfare and medical treatment. Whether or not faith and medical treatment are opposed to each other, and the further challenge of mediating between an individual’s faith and a secular, clinical duty to save his or her life are questions of profound significance within medical ethics.

However, there is a sense in which the novel fails to address these questions adequately. The legal and ethical questions are literally dissolved by a solution of ‘having your cake and eating it too’ (p.  138). The evidence presented by the witnesses also trivialises the nature of the case. On the question of whether or not Adam is competent to make his own decision, the only evidence presented in court is a statement made by Adam’s parents. Fiona does not receive any thorough psychological assessments of Adam’s intelligence or maturity by consulting psychiatrists, or any clear medical assessment as to whether or not he is intelligent or mature enough to fully understand his decision. Instead, she bases her decision on grounds that are entirely wishy-washy: she visits Adam in the hospital and hears him play the violin and recite his poetry. While this does, to some extent, mirror Sir Ward’s decision as he presided over the case that inspired this novel, one crucial difference in the novel is that Fiona’s personal life intrudes upon her legal judgment: because of her failing marriage and her childlessness, she develops a personal attachment with Adam, and it is this personal attachment that motivates her judgment. This is a breach of legal professionalism for which Fiona suffers no adverse consequence later on. The novel’s treatment of the case does not adequately reflect the nuance or complexity of the issues at hand, and by glossing over the nuances of the legal or medical processes it egregiously misrepresents both the medical and the legal profession.

After she delivers her judgement, the novel does not dwell on the ethical or legal repercussions of Fiona’s decision, but focusses instead on her mid-life crisis. Adam’s subsequent death and Fiona’s guilt in having played a hand in it become the basis for her reconciliation with her husband. The legal and medico-ethical questions the novel raises become accessories to the story of her and her husband’s strained relationship. Much like McEwan’s previous novels about medicine, this is the most disappointing aspect of the novel, as the complex medical debates are relegated to the background. The treatment of these debates renders them a canvas on which the existential angst of middle-class characters is played out rather than a sophisticated, critical engagement with the debates themselves. The medical and jurisprudential questions that The Children Act raises are of fundamental importance. It is a shame that the novel’s treatment of these issues fails to resolve in a manner that is meaningful.

Reviewed by Vivek Santayana, who is a postgraduate student at the University of Edinburgh. Within the medical humanities, he is mainly interested in narrative ethics, literary representations of medicine, literature and psychotherapy and medical-ethical debates. Vivek has previously reviewed ‘Cutting for Stone‘ for the CMH site, as well as J.M. Coetzee and Arabella Kurtz’s The Good Story: Exchanges on Truth, Fiction and Psychotherapy and the new Pixar film Inside Out for the BMJ Medical Humanities blog. He is also one of the organisers of the Medicine in Literature Reading Group at the University of Edinburgh. Besides the medical humanities, his research interests include postcolonialism, postmodernism, ecocriticism, literature and science, continental philosophy and the history and philosophy of science. 

Correspondence to Vivek Santayana

Works Cited

McEwan, Ian. ‘The law versus religious belief,’ The Guardian, September 5, 2014.

Press Association. ‘Judge rules Jehovah’s Witness boy can receive blood transfusion,’ The Guardian, December 8, 2014.


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