Tuesday, April 25, 2006

Unwanted

The baby was very tiny and immature. After eight days of life, not only were her lungs in bad shape but her liver and kidneys were failing too. My partners and I met to discuss whether ongoing treatment was futile, whether we were prolonging suffering; whether we should take the baby off the ventilator and allow her to die.

The mother of this baby was a black drug addict, who I think was homeless, and certainly had little to no social support. She rarely, if ever, visited. As we discussed what to do with the baby, one of my partners, to my surprise, said that he thought that one of the factors in our decision should be the baby's social status. The baby was, in effect, unwanted. That made it easier, said my partner, to let the baby die, easier than if the baby had loving, caring parents who really wanted the baby.

I was a bit flabbergasted by that remark. (I was also a bit puzzled, since that remark was out of character for my partner; he is a fine and empathetic neonatologist.) I thought that all babies had an inherent self worth, regardless of the parents' social standing. If we let social standing influence these decisions, the potential for discrimination was great. Would factors like race or gender influence our decisions, even though none of us thought we were racist or sexist? Would a family's income affect us? Would we think that babies with wealthier parents were more wanted?

Although I disagreed with my partner - and still do - he had a point, sadly, about the child being unwanted. This child, if she lived, would have almost certainly gone into foster care, where many of the babies bounce from home to home until they reach age 18 and are left to fend for themselves. Black babies born to drug addicted moms are not prime candidates for permanent adoption, and home life with her biologic mom was pretty much out of the question.

We ended up recommending to the mother that life support be removed. She agreed, we did so, and the baby died. I was on service, so the final call was mine, and I can assure you that we removed the ventilator because further treatment was futile, not because of the baby's social standing. The mother came in when her baby died and genuinely wept and grieved for her. Unplanned for with no place to go? Maybe. Unwanted? I don't think so.

P.S. A new Grand Rounds, version 2:31, is up at the Health Business Blog.

P.P.S. Check out the first edition of Pediatric Grand Rounds at Unintelligent Design.

12 Comments:

Blogger Kelly said...

This is such a touchy subject, and I don't really know how I truly feel about it, but what about this angle:

Is it possible that because of that baby's inherent "social status" and her mother's life situation, that removing life support was merciful, and therefore could be used as a factor in determining whether or not to go through with intervention after intervention?

That perhaps because her mother couldn't care for her, and a life of foster home after foster home was likely, that playing "super doc" for potential futility was not as warranted (bad word, I know) as if the parents were right there pushing you to keep going-also for futility?

Wow. Very interesting ethically, I think. My first thought is that it was more merciful for the child--but who's to say? That one could've been the next Nobel winner, or the next Maya Angelou. Or even my favorite Walmart cashier...

I guess the safest bet is to handle it as YOU did. But I can see your colleague's thought process, too. I'd hate to be in his shoes.

11:53 AM  
Blogger Ex Utero said...

Hmm, I don't think its ever good to have an algorhythm for removal from life support. Every case is different. In the end, if there's a parent who's willing to participate in the decision process, even if she's down and out, her vote counts as much if not more than all the MDs put together. The day we start rationing care based on social status is the day that I find another line of work.

1:38 PM  
Blogger Flea said...

I agree with you and Dr. Gordon,

The category "wantedness" is way too slippery a peg on which to hang life or death decisions such as these.

best,

Flea

4:46 PM  
Blogger Dream Mom said...

What a sad situation. I don't think the "social status" should have had any effect on the decision. Whether the baby's natural mother wanted her or not is irrelevant. Perhaps there was another woman who would have loved to have that baby and who would have loved her like no other. And, should your worth as a human being, or decisons about you made on the basis of "who" is your mother?

I am beginning to notice a disturbing trend in the world in general when it comes to money. People are beginning to make decisions about people based on how much money they have and it's just not right. Somehow, the more money you have, the more "rights" you have or the more that you are "entitled" to. Just an observation on my part.

Along this same line, I have noticed something disturbing at the hospital that I take my son. They have added the type of insurance that a person has to the patient's wrist band. I can only imagine the reimbursement rate for the surgical procedure or whatever flashing in the surgeon's head or everyone in the room.

9:44 PM  
Blogger Lisa said...

I am a former foster child.

I have a college education. A Master's degree. A husband and two stepchildren.

I'm a children's librarian, and I have given workshops at several conferences.

Please tell your colleague that, in that moment, he was just being logical.

But, his logic was wrong.

10:52 PM  
Blogger Cathy said...

Like Dream Mom has said, I worry about the emphasis being put on money and ins. in the medical field. If people think it (money and social standing) doesn't matter or cross drs. mind then they should read some of the BLOGs out there and listen to what some of these Drs. say about (less than fortunate) people and families".

I also think it was normal for your collegue to have the thoughts he had. But, those thoughts should stay buried in the back of someone's mind. They should not be discussed and certainly not considered.

2:28 PM  
Blogger neonataldoc said...

Great comments, everyone. Thank you. We'll keep individualizing these decisions. And I hope we never put insurance status on patients' ID bands. There's enough chance of discrimination as it is.

9:58 AM  
Anonymous Kim said...

Heart-wrenching. And in the end I ached for the mother. Not something I expected to do at the beginning.

4:38 AM  
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