Should Every Baby Be Saved?

By Dick Thompson

The unnamed baby boy, born three months prematurely at Children's Hospital in Washington, is one of thousands of 2-lb. problems facing medicine. For more than a month he has been kept alive inside a plastic incubator. Miniature sunglasses are taped over his eyes, IV lines are cut into his neck, and tubes have been jammed up his nose and down his throat. Although $2,000 a day is being spent to keep this child alive, he will be permanently handicapped if he ever leaves the hospital. But it is unlikely that this infant will go home. "This baby is the dilemma," says Dr. Maureen Edwards, director of newborn services at the hospital. "You've started treatment, and there's no place to stop, and you're not going to save the baby."

There was a time when that child would almost certainly have died soon after birth. In recent years, however, scientists have learned to build and maintain artificial wombs to give extremely premature infants a fighting chance. The result is that their odds of surviving are increasing rapidly. Before 1975 only 6% of babies with birth weights under 2 lb. 3 oz. managed to live. By the first half of the 1980s, the last period for which national statistics are available, the survival rate for such children had jumped to 48%. Doctors say the odds have continued to improve.

But the price, both financial and physical, can be devastating. In one study of care for the smallest preemies at Stanford University Hospital, the average cost was about $160,000. Nationally $2.6 billion is spent on neonatal intensive care each year, according to a recent report published in the American Journal of Diseases of Children. Despite the extraordinary measures taken, half the survivors face a lifetime of disabilities. Now ethicists are asking if it is time to consider limiting treatment to conserve health-care dollars and reduce suffering. Says Stanford ethicist Ernle Young, one of the A.J.D.C. authors: "To do cost-ineffective things, without being assured the results will be beneficial, will be increasingly seen as irresponsible."

In the U.S. federal laws require doctors to begin treatment of all babies except those who would clearly not benefit. But no regulations guide a physician's decision to stop treatment. This has become a pressing issue because the very technology that can save infants often inflicts profound ; handicaps, such as blindness, cerebral palsy and other neurological disorders. Among the effects of erring on the side of life, say the authors: "We save some who would otherwise have died, we do immediate harm to and inflict long- term suffering on many who survive, and we expend an enormous amount of money on neonatal intensive care."

Limiting treatment is already a common practice in Europe. In Sweden, if the outlook for a baby is uncertain or grim, doctors make no effort to save the infant, report the A.J.D.C. authors. In Britain treatment in most hospitals begins immediately on all viable newborns, but periodically the prospects are re-evaluated, and if severe brain damage or death seems likely, efforts are stopped. That decision is made after consulting with the infant's parents.

In France only the medical team is believed capable of making the decision to start or stop treatment. Even the wishes of the parents would not necessarily overrule the physicians' judgment if severe brain damage was discovered. Says Dr. J.P. Relier, head of a French neonatal resuscitation unit: "I think our responsibility as doctors is not to give a family a handicapped child." Such an attitude is not likely to be embraced in the U.S., where it is widely felt that life has its own value, handicapped or not.

Many premature births, and the agonizing decisions that follow, could be avoided if more expectant mothers received adequate prenatal care. In America care often becomes a matter of economics and social standing. While the upper and middle classes buy excellent treatment, poor pregnant women often fail to see doctors, even when the costs could be covered by Medicaid insurance. Adding to the problem is the drug epidemic. In some inner-city hospitals, 30% of the babies admitted to neonatal-intensive-care units are born to mothers who use crack or other drugs that induce prematurity.

The unevenness of prenatal care has kept the rate of premature births in the U.S. stuck at 7%, despite growing knowledge of how to prevent such cases. Observes bioethicist Daniel Callahan, director of the Hastings Center in Briarcliff Manor, N.Y.: "This is craziness. Large amounts are being spent on rescue technology." These outlays would not be needed, he argues, if smaller amounts were spent on prenatal care. But expenditures on high technology, says Callahan, are attractive to Americans because the results are immediate and apparent, in this case the survival of otherwise doomed babies. The payoff on an investment in prenatal care is obvious only in the statistics.

The ethical issues are becoming difficult to avoid. This month another group of researchers will report that specialized follow-up care for handicapped preemies can reduce the impact of their disabilities. Yet that care is certain to add more expense to the preemie bill and exacerbate an already vexing situation. It is cruel and irresponsible for society to ask a physician looking into a plastic incubator to decide a question of public health policy. But until the nation grapples with just that issue, doctors will be given the thankless task by default.

CHART: NOT AVAILABLE

CREDIT: TIME Chart

CAPTION: Chances of survival for babies weighing:

With reporting by Tala Skari/Paris