Change

I have written before about the ethics of resuscitating babies of 23 and 24 weeks gestation and of my discomfort at allowing parents to decline resuscitation of a 24 weeker when there is a 55 - 60% chance of survival and 25% chance of severe disability, especially when there would be no question of resuscitating and treating an older patient with those odds. At the risk of alienating readers by repetition, I'm going to talk about it again, because the July issue of Pediatrics has a letter entitled "Advocating for the Very Preterm Infant", which basically agrees with my point. It's kind of exciting for me, because this is the first time in my memory that I've seen such a piece in the medical literature.

The letter is written by Drs. Annie Janvier and Keith J. Barrington, neonatologists from McGill University in Montreal, in response to a previous article discussing guidelines for resuscitation and non-resuscitation of extremely premature babies, an article in which the majority of medical staff members at an NICU in Portland, Oregon did not recommend NICU care, but just palliative care, for infants born at 24 weeks. Dr. Barrington is a well respected neonatologist, one invited to write editorials and give talks at prominent conferences. The letter speaks of "the ethical duty of the perinatal team to the infant about to be born." The authors note that a one month old infant with group B strep meningitis or a 50 year old neonatologist with an extensive stroke, both of whom have survival and disability chances similar to those of a 24 weeker, would likely have "immediate resuscitation and institution of care without any discussion of withholding intervention". Why, then, is it acceptable to not resuscitate 24 weekers?

Judging from comments on my previous posts about this subject, the majority of readers strongly feel that it should be the parents' decision to provide aggressive care or not. (Actually, it's not clear from the letter whether the authors think all 24 weekers should be resuscitated or whether they think it should be the parents' choice.) I know that's the prevailing thought, but I'm still not sure it's appropriate. It is plain and simple age discrimination when we don't resuscitate 24 weekers when we would resuscitate patients such as those mentioned above.

Drs. Janvier and Barrington have a little twist in their situation. Not only are they neonatologists, but they are also parents of a baby born last year at less than 25 weeks gestation. They write "Every day that goes past we are grateful to our colleagues here" for resuscitating their baby.

In the 1980's it took a Baby Doe case and government intervention to force people to repair such defects as esophageal atresia in Down syndrome babies, instead of just letting them die because they had Down syndrome. Although I really prefer to not have the government involved, I wonder if we need another Baby Doe case this decade to change our paradigm and insure aggressive treatment of 24 weekers.