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Technically, preemies born as early as 22 weeks gestation could survive (Allen et al., 1993). However, one may wonder whether this is also the ethical limit of viability: most preemies born at this age, will die in the Neonatal Intensive Care Unit (NICU), and those who do survive, often have severe disabilities. Some parents and physicians are therefore advocating to allow treatment to be terminated - or not initiated in the first place - if the outcome looks unfavourable. This, of course, raises still more moral questions about the right to die vs. right to life, who makes life-or-death decisions about preemies (parents, doctors or the government) and, if decisions against resuscitation or aggressive treatments can be made on the basis of a probably negative outcome, what is considered negative.
In my view, it is impossible to predict a preemie's outcome solely on the basis of one factor, whether it be birthweight, as is often happening in the United States, gestational age, as is the general belief here in the Netherlands, or anything else. There are many factors contributing to how an infant will do. Gestational age is among them - over 90% of preemies born at 27 weeks survive, while the chances of survival for a 22-weeker are less than 10% -, of course, and so is birthweight. However, gender - girls do better than boys - and even ethnicity, contribute as well. When trying to determine the possible outcome after treatment has been initiated, an MRI-scan of the brain can be helpful, cause Intraventricular Haemorrhage (brain bleed) and other brain anomalies are among the leading causes of disability in preemies: of preemies with a normal MRI after one day, 75% later function normally (De Visser, 2004).
In the Netherlands, as a general rule, babies born before 25 weeks gestation, will not be admitted to the NICU and will, hence, be left to die without treatment ever having been initiated. It is also legal to terminate treatment once initiated, but this doesn't appear to happen often. In the United States, preemies' treatment is sometimes terminated when it would not be effective in sustaining the infant's life, but terminating treatment based on neurological outcomes, is very rare (Singh et al., 2004). Actively euthanizing preemies is illegal, but would most likely have been tolerated in the Netherlands, but it's not happened as far as I know.
The advantage of not initiating treatment in the first place, in my view, is only that it "feels" better than to terminate treatment, cause less will be known about the individual child and he or she will be more like a "statistic". To ethicists, the two are, however, the same. Furthermore, deciding in a later stage does allow to "select" more individually, hence allowing those 24-weekers without brain damage to live, who would have been left to die on the basis of their gestational age and/or birthweight. And indeed, it would also allow doctors to terminate treatment of the 26-weeker with a grade IV brain bleed and many other NICU complications.
Some parents, united in Neonatology and Rights of Families, claim that doctors leave them no choice of whether to have their preemies treated, now leaving them with children with severe disabilities. These families advocate parent informed consent on treatment. Informatin should include statistics on later outcomes of premature babies, so that parents can make the decision not to have their infant treated. These families' initial claim, that doctors generally want to treat preemies while parents don't, is however not representative: most parents want more treatment than do physicians, and often these doctors then see the parents as responsible for the decision being made (Dorn et al., 1988).
This question cannot be answered objectively, of course, but it is important for the discussion of which preemies to treat and whom to let die. It is also important in setting guideliens for this purpose, such as the Dutch national guideline not to treat anyone born before 25 weeks gestation. Cause all of these guidelines, and many individual decisions by families or physicians, are based on statistics, it's important to wonder what statistics to look for. Is a severe brain bleed, indeed, the basis for worry? It is generally known that babies with grade IV haemorrhage or those with a brain bleed followed by hydrocephalus, are at high risk for disability, but it'd personally suit me if this statistic were not the basis for treatment decisions, as a person with a brain bleed of unknown severity and subsequent hydrocephalus whose could-be neurological issues are minor and undiagnosed.
This, already, makes clear that if decisions are based on statistical predictions of outcome, they'll never be objective: it can be said with some reliability that preemies who develop hydrocephalus as a result of an IVH, or preemies born at 23 weeks, or preemies having any other characteristic studied in medicine, have such and such a statistical risk of getting this or that disability. However, most disabilities are not diagnosed in individuals till long after discharge and, even though major disabilities like blindness or severe cerebral palsy, are being diagnosed in the first two years, school-age preemies run a risk of having behaviour difficulties, ADHD or learning disabilities that cannot be diagnosed in early childhood. Therefore, selection will never be on what is a preemie's outcome, but on what might be, unless we're going to allow active euthanasia on disabled children.
Another factor that makes drawing conclusions about "negative" outcomes difficult, is that no-one can say with objectivity what is a negative outcome. A family may say that they don't want to raise a mentally retarded child, for example, but should this be the basis for killing? I don't suppose so. One may say that, upon discharge from the NICU, so many percent of the preemies have brain damage, so many have an eye condition, and so many have lung disease, for instance, but it does not say anything about these children's quality of life: I am far more at peace with my major disability of blindness than I am with my undiagnosed issues that are bordering on a normal variant of individuality.
Therefore, what one considers a life worth living, is very speculative, and neither families, nor disabled people themselves, medical professionals nor the government can decide on this objectively. It is often said that a certain state is obviously not worth living in. For instance, most people I know would contend that Terri Schiavo's life was not worth living, while her parents and numerous pro-life groups clearly thought it was, and both sides claimed to know what Terri would've wanted. In such circumstances, where a person cannot express his or her own will - and preemies fall within this category -, it is often more about what is acceptable to the family, the doctor, or the government, that makes the difference, and we all may wonder if these people have the right to decide over another person's life.
Therefore, it is very hard to decide on a universal policy on treatment for preemies, since firstly it may be questioned who has the right to decide on these matters, and secondly once this has been determined by whoever is an appropriate person or agency to do so, predicting a preemie's actual outcome is so speculative, that no decisisons along the lines of "We aren't going to treat babies who'll become mentally retarded" can be made. Now it in my view wouldn't be desirable to have a universal policy along those lines, but it is true that any other policy on preemie treatment would be based on statistics, and any individual decision about a baby would be based on estimations about a child's outcome.
Allen MC, Donohue PK, and Dusman AE, The Limit of Viability -- Neonatal Outcome of Infants Born at 22 to 25 Weeks' Gestation. N Engl J Med, Nov 1993; 329:1597-1601
De Vissser E, "Sommige te vroeg geboren kinderen gaan later naar de universiteit". De Volkskrant, 02 Oct 2004
Dorn MW, Vennes-Meehan KA, Margolis LH, Holoman, EM, and Stiles AD, Delivery Room Resuscitation Decisions for Extremely Premature Infants. Pediatrics, Sept 1988; 102: 574-582
Singh J, Lantos J, Meadow W, End-of-Life After Birth: Death and Dying in a Neonatal Intensive Care Unit. Pediatrics, Dec 2004; 114: 1620-1626