Ethics at the Limit of Viability: A Premie’s Progress

Abstract

After completing this article, readers should be able to: 1. List the five epidemiologic truths that underlie ethical decision-making in the neonatal intensive care unit. 2. Describe how recent developments have altered some, but not all, of these epidemiologic observations. Progress in neonatology is generally portrayed as inexorable—doing better and better with smaller and smaller. For approximately the first 30 years of the specialty, this was true. A succession of manuscripts published between 1960 and 1990 bore witness to the success, with titles such as “1,500 g: How Small is Too Small?” that subsequently were followed by: 1,000 g:?, 800 g:?, and 500 g:?. By 1990, virtually all neonatal intensive care units (NICUs) had survival rates of 90% or greater for infants whose birthweights (BWs) were greater than 1,000 g. Consequently, for individual infants whose BWs were greater than 1 kg, parental refusal of intervention was precluded in the absence of other, nonBW-related circumstances. At the other end of a relatively narrow BW spectrum (approximately <450 g), survival was dismal. At a minimum, parental requests for nonresuscitation of infants who weighed less than this limit seemed supportable, under the broad rubric of futility. Thus, the ethical debate surrounding NICU care was played out along a birthweight dimension of roughly 1 lb. These epidemiologic truths were recognized by the early 1990s. However, much has changed in NICU care in the past decade. Exogenous surfactants are administered uniformly for respiratory distress. High-frequency oscillation and inhaled nitric oxide are widely available. Antenatal corticosteroids have become standard therapy for women in whom preterm delivery is threatened. In this brief article, we consider how these medical advances affected both the epidemiology and ethics of life and death for extremely low-birthweight (ELBW) infants in the NICU during the past 10 years. In parallel with Newton’s three laws for …