A new article in Bioethics criticises policies in neonatal care units that mandate the withholding of treatment from babies born before 25 weeks gestation.
Neonatologist Manya J Hendriks (University Hospital Zurich) and paediatrician John D Lantos (Children’s Mercy Hospital) argue that many extremely premature babies -- babies born between 22 weeks and 25 weeks gestation -- can survive and, indeed, develop healthily if given adequate treatment. Yet many neonatal intensive care units in Europe and North America have policies based on estimated-gestation age (EGA), and these units routinely withhold treatment from extremely premature infants based solely or primarily on the fact that they were born before 25 weeks gestation. Units in France and the Netherlands will typically not intervene in cases where children were born prior to 24 weeks gestation, and in North America there is wild variation among the treatment policies of different units.
According to the authors, EGA-based policies are “contrary to both medical norms and to most theories of justice”. Instead, the authors argue for an “individualised approach” to treatment decisions based upon the likelihood of an intervention’s success.
The criteria for limiting treatment in preemies, as in any patient group, should include a combination of (a) poor prognosis for survival, (b) likelihood of unacceptable disabilities, (c) burdens of treatment, (d) costs and cost-effectiveness, and (e) informed consent and shared decision-making with parents. A just system would apply those criteria to all patient groups. Our current approach of denying treatment to some premature babies when it is provided in situations where it is less cost-effective to patients with a worse prognosis is unjust.
In evaluating current neonatal care policies, the authors speculate that neonates are sometimes seen as “conditional persons” with less of a claim on our health care resources than fully-developed adult human beings. The authors argue that this view is contrary to basic egalitarian principles:
We assert that newborns, even those born prematurely, are full-fledged members of the human community and have the same right to treatment as other humans. This entails giving extreme preterm babies the best possible chance to life. Policies and practices that limit treatment based on gestational age alone violate this basic principle of justice.
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