The Ethics of neonatal care from The Observer January 28th 2008

Read the article below and discuss the issue: “Morally should we try to save very premature babies?”

Babies are usually born at 40 weeks and anything under 37 weeks’ gestation is defined as premature. Increasingly, however, hospitals are reporting that babies are surviving much earlier births, sometimes after a gestation period of just 22 weeks; an age at which some foetuses can still be legally aborted.
Extremely premature babies, those born earlier than 26 weeks’ gestation, have a fragile hold on life. More than 50 per cent die, some making it no further than the delivery room. No one is sure why more premature babies are being born today, but thanks to advancing medical knowledge and skills these children have a better chance of surviving than ever before. At 26 weeks a child has a 75 per cent chance of life, albeit one possibly marred by disability and impairment. A child’s chance of survival, however, drops steeply with every day less spent in their mother’s womb: 23-week old Janie had only a 25 per cent chance of survival when she was born.
Ironically, it is the miracles wrought by doctors such as Costeloe that have laid the foundations for a slew of difficult questions, so ethically and morally sensitive that experts are reluctant to address them. For example, with intensive care cot charges reaching as much as £2,384 a day, a premature baby will cost the NHS five times more than a full-term baby by the time it leaves hospital. In a health service with finite resources, battling to save the lives of the few most desperate cases – the 23-weekers who need many months of intensive care to have a chance of survival – may compromise the care given to older babies, many of whom have a far better prognosis.
In situations like these, where should doctors draw the line? Should there be a cut-off point for treatment, where no baby under a certain age is offered intensive care, or should doctors be able to choose which babies they will help to live – and which they will leave to die?
‘The legal position is very grey, but my Hippocratic duty as a doctor is even less clear,’ says Dr Shad Hussain, who has worked in the Homerton’s neonatal unit for 12 years. ‘As a doctor, I am here to save lives, and if I have a baby born with a sign of life that could be just a heart rate, should I say that, because I believe the outcome will be so poor, I won’t do anything at all?’
If Hussain does decide to start treatment, however, he points out that it simply opens up the possibility that he will be faced with an even more agonising choice. ‘When should that treatment cease?’ he asks. ‘Is it right to prolong a baby’s life at all costs or is there something worse than death for both the child and their family; namely, severe and profound disability?
The futures of extremely premature children as they grow through adolescence and into adulthood are unknown. The first EPICure study, jointly led by Costeloe in 2005, traced the 1,125 babies born in England in 1995 at under 26 weeks of gestation. Of these, only 314 survived and went home.
Costeloe discovered that four in every five had developed a physical or learning disability linked to their prematurity, and sometimes both. At the age of six, about 10 per cent had severe cerebral palsy and around 40 per cent had moderate to severe learning difficulties, 40 per cent higher than the average rate. Just one of the surviving children born at 23 weeks in 1995 had no disabilities or impairments at all.
‘Many doctors saw the high rates of disability and asked whether they were still justified in fighting to save the lives of babies born at the limits of viability,’ says Costeloe. ‘Others of us identify challenges such as improving nutrition and reducing episodes of infection that we believe could lead to a reduction in the burden of morbidity among survivors.’