Resuscitating and prolonging life

The Nuffield Council on Bioethics’ “Working Party on Critical Care Decisions in Fetal and Neonatal Medicine” setting week-by-week guidelines for the treatment and resuscitation of newborns will be released today, November 16, 2006. In the meantime, based on news reports and last week’s unethical statement by the Royal College of Obstetricians and Gynaecologists, the blogosphere is full of assumptions, judgements and even quite a bit of reasoned discussion about what is expected to be in the report. I’m not surprised that the comments are similar to the discussions about care for patients at the end of life, in content and divisiveness among prolife advocates.

Here is a “White Paper” summary of the report, published in The Scientist on November 15, and authored by the chair of the Council, Margaret Brazier.

The actual report evidently draws a line for “struggling” premies at 22 weeks gestation, saying that they should not be routinely resuscitated and taken to the Neonatal Intensive Care Unit (NICU), except when enrolled in experimental trials. The British Medical Association has already released a statement emphasizing that doctors should make clinical judgments on a case by case basis, rather than following arbitrary timelines. It’s expected that the Report will suggest allowing babies who are not expected to live in spite of intervention to die a natural death. There is never a suggestion in the Report of the Working Party that babies’ lives should be deliberately ended, although there is the recognition that some attempts to relieve pain may carry an unintentioned but known risk of speeding death. The report also concludes that there is no ethical difference between withholding and withdrawing treatment that will not preserve life.

Unfortunately, I don’t think any US schools use the Hippocratic oath anymore. (Here’s a concise article on the newer oaths that focus on relieving suffering rather than honoring the sanctity of life and which include promising to manage “finite resources.” I can’t count the number of times I hear “finite resources,” which just means “taxes.”)

However, the original Hippocratic oath says, “Heal when possible, but first do no harm.”

We doctors can do so much harm using the tools we have at the medical centers where these babies are cared for. After all, most of the centers are research and teaching schools. We make strides by experimenting and the medical students and residents need to learn. But there must be a point at which we say, “This much and no more,” without ever acting to intentionally cause death. In other words, it is acceptible to withdraw or withhold a ventilator or feeding tube, but it’s never acceptible to smother the child or inject poison that’s intended to cause immediate death.

If we are keeping the babies alive for the sake of proving we can keep them alive by our skills and technology, to avoid malpractice lawsuits or because the family can’t let go, and we can see that the treatments are in fact only prolonging death for a child who can only feel pain and never process and understand that pain, we are wrong. We should not keep the child alive for our sakes, but only for his.

An interesting point in light of the RCOG’s recommendation that there be more discussion about intentionally killing some children is made in this article in the UK Telegraph.
It seems that abortion is prohibited in most cases from the 24th week in the UK. For a couple of weeks, the babies who would be resuscitated under the guidelines of the Working Party could legally be aborted. The Telegraph editorial suggests that doctors should urge the Members of Parliament to reconsider their recent refusal to lower the limit on abortion on demand to 21 weeks.