REVIEWED BY MICHAEL PANICOLA, Ph.D.
Neonatal Bioethics: The Moral Challenges of Medical Innovation
By John D. Lantos, M.D. and William L. Meadow, M.D., Ph.D.
Johns Hopkins University Press, 2008
192 pages, $25
www.press.jhu.edu
Based on its title, one might expect to find in Drs. Lantos' and Meadow's book a fairly typical treatment of neonatal bioethics with the main focus on tragic, life-and-death treatment decisions for premature babies occasioned by technological advances in neonatal medicine. To be sure, there is some of this, at least from a historical viewpoint. However, Neonatal Bioethics is less a contemporary update to such books as Robert Weir's classic Selective Nontreatment of Handicapped Newborns (Oxford University Press, 1984) than it is a probing reflection on neonatal medicine more along the lines of Shannon Brownlee's excellent Overtreated (Bloomsbury, 2007).
In Neonatal Bioethics Drs. Lantos and Meadow examine medical innovations in neonatology and describe the "iterative, nonlinear and, sometimes, heated process" (p. 8) by which a tentative societal consensus evolved with regard to complex moral, legal, economic and political questions. The book is an easy, fascinating and fairly short read, with the bulk consisting of three chapters that describe distinct eras in the history of neonatal medicine.
The first is the "Era of Innovation" (1965-1982) during which neonatology had some its most dramatic successes with the regionalization of perinatal care and the introduction of mechanical ventilation and total parenteral nutrition for premature babies. While these innovations made modern neonatal intensive care possible, progress often outpaced moral reflection as parents, physicians and society were for the most part unprepared to grapple with the questions of which babies should receive the new therapies, when the therapies should be initiated and, even more frightening, when they should be withdrawn.
The second era described in the book is the "Era of Exposed Ignorance" (1982-1992) during which innovations continued (e.g., surfactant and antenatal steroids) but in a less dramatic way as the focus shifted to a refinement of "both the technologies and the societal mechanisms by which the use of the technologies were governed" (p. 85). Unlike the first era, when the prevailing concern was whether physicians were being too zealous in their attempts to "save" premature babies with the new tools at their disposal, this era was dominated by almost the exact opposite concern. With improvements in survival rates among critically ill newborns, yet significant morbidity or disability among some survivors, the concern arose that treatments necessary to save the lives of some impaired newborns were being withheld on quality of life grounds. This concern was fueled by news reports and legal cases, such as that of Baby Doe in Bloomington, Ind., and led to the federal government's intervention into neonatal medicine and the ultimately unsuccessful attempt to create national standards for neonatal treatment decisions.
The third era described in the book is the "End of Medical Progress" (1992-Present) during which no new major innovations in neonatology have materialized and improvements in birthweight-specific survival rates have come to a halt. Though some lament the lack of progress in this current era, the upside is that it has given physicians a chance to refine prognostic accuracy so that better ethical decisions can be made in the neonatal context, and it has given society a chance to reflect on elements of consensus. The authors summarize this hard-fought societal consensus toward the end of their book.
As a society, we have made a serious commitment to both prenatal and neonatal intensive care. As a society, we have shown a willingness to prohibit some quality of life decisions but to allow others. As a society, we have decided that neither doctors nor parents alone may decide when life-sustaining treatment ought to be withheld or withdrawn. Instead, doctors and parents together must agree to stop treatment or else treatment will continue. This approach is expensive but it saves lives, preserves important moral values and does not seem to have morally intolerable long-term sequelae for individuals, families or society (p. 149).
Neonatal Bioethics is an excellent addition to the growing body of literature in health care ethics. In it the authors may not offer simple or definitive answers to the questions they raise. But they do provide insight into how innovation occurs in medicine, how that innovation gives rise to complex issues that stretch across moral, legal, economic and political boundaries, and how societal consensus can be achieved if we have "the courage to allow ourselves doubt" (p.149).
While health care professionals within neonatal medicine will find the book most useful, it has relevance for a much wider audience, including other health care professionals, medical and nursing students and ethicists.
— Michael Panicola, Ph.D., corporate vice president, ethics, SSM Health Care, St. Louis.
Copyright © 2009 by the Catholic Health Association of the United States
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