One, an eight year old boy and his family are counselled by a pediatric oncologist about treatment for his lymphoma. She gives the child a 50% to 60% chance of survival with the best treatment, a combination of chemotherapy and radiation, with the child having about a 50% chance of serious brain damage from the treatment. The parents decline the treatment and opt to give the child comfort care at home.
Two, a woman pregnant at 24 weeks gestation and in preterm labor and her husband are counselled by a neonatologist about the baby's chances of survival if she delivers at this gestation. The baby has a 50% to 60% chance of survival if resuscitated fully at birth and put on life support, with about a 5o% chance of serious brain damage if he survives. The parents decline to have the baby resuscitated and opt for comfort care only.
The above vignettes are fictional, although the numbers for the 24 week pregnancy are accurate, and I and many other neonatologists have had a similar discussion with parents many times. I wonder, though, what the response in each case was to the parents' refusal of aggressive treatment. I suspect that for the 8 year old, there would be many who think it appropriate to call the child protective services agency or the courts to force the child to have treatment. For the baby, though, it is well accepted that parents can decline treatment and let the baby die. (There is an article in the January Pediatrics that describes one hospital's guidelines about resuscitating babies that shows the majority of caregivers would accept the parents' decision to forego resuscitation. I think their experience is similar to most NICU's around the country.) I have never heard of anyone trying to get the courts to force resuscitation of a just born extremely premature baby.
Yet what is the difference between the two patients, the eight year old with lymphoma and the few minutes old premature baby? Both are alive, separate from the mother. What is it about the very beginning of life that allows us to let the baby die when we might insist on treatment for the 8 year old? Is it because over 8 years we have had time to become attached to the child, to see him develop a personality?
Or is there no difference? If we insist on treatment for the one, should we do the same for the other? Is it age discrimination if we allow the baby to die and not the 8 year old?
This is not merely a hypothetical situation. Every day decisions are made whether to resuscitate babies of 23 to 24 weeks gestation, at the so called "border of viability." Personally I have a little trouble denying care to them when we would not allow that to happen if the child were older. (And, in fact, most parents at 24 weeks gestation do opt to have their baby receive full support.) But there is a discrepancy, and I can't quite figure it out.