Is the Glass 10% Empty or 90% Full?
John Kattwinkel, MDRobert Boyle, MD
Department of Pediatrics
University of Virginia
Charlottesville, VA 22908
Dr Silverman recently wrote another commentary chastising the neonatology profession for its lack of compassion in rescuing "extremely small or severely malformed neonates in the United States."1 He used as examples of this supposed travesty an anesthesiologist who slashed open the chest of a 23-weeks' gestation infant to give open-chest cardiac massage and quotes from unidentified sources (one from an intensivist claiming that "[we] can bring a peach back from death") and others from understandably distraught parents whose children had bad outcomes after births that took place nearly 20 years ago. He suggests that this supposedly barbarous subspecialty is being driven by "opportunism" and to fuel "profit centers," with little evidence of compassion.
Are we neonatologists really all that callous, or is this a jaundiced view, perhaps not substantiated by the evidence? Although anyone would certainly sympathize with the quoted-parents' situations, there are many more normal children who are alive and well because of the care provided to the highest-risk neonates. If none of these high-risk children had been treated aggressively, none would have survived, none would be impaired, and none would be normal. How many normal children are we willing to sacrifice in order to prevent 1 case of cerebral palsy? There is no doubt that this is a sensitive issue that warrants careful ongoing examination, but the evaluation should be based on comprehensive data and not on isolated testimony from a few of the failures. The data would suggest that the outcome is not nearly as bleak as Dr Silverman has proposed.2,3 Even those children and parents who have had a bad outcome may not be as bitter as Dr Silverman has portrayed some parents to be.4,5
Dr Silverman gives only fleeting recognition of the 5-fold decrease in infant mortality that has taken place since the era in which he practiced6 and the tens of thousands of infants who would have died but instead have become normal, productive citizens over the past 50 years. He implies that we may have been more compassionate when we permitted the 1000-g premature infant (who now has a 90% chance of intact survival) to gasp in the corner unattended until death, without even informing the mother of his/her live birth. He fails to recognize the national guidelines that have been developed for when not to resuscitate, how appropriate it is to withdraw support from a severely damaged infant, and how important it is to involve the parents in the decision-making.7–9 He fails to acknowledge that more than three fourths of resuscitated infants who go on to die in neonatal intensive care units do so because the parents and the clinicians agree that it is the best choice.8 He makes no mention of the unpredictability of long-term potential of most high-risk infants at the time of birth and implies through the quotes from distraught parents that the eventual outcome is crystal clear whenever a newborn is resuscitated. He quotes a figure of $11.9 billion spent on prematurity but fails to note that this is 2% of that spent on hospitalization of older citizens and <0.8% of the annual US health expenditure.10
Certainly there are abuses of the system and those who have profited excessively from making inappropriate clinical decisions. Certainly there are examples of children who, in retrospect, might have been better off having not been resuscitated, but let's put things in perspective and at least recognize the tremendous accomplishments of the past 4 to 5 decades. The vast majority of neonatologists and their nursing colleagues are caring, sensitive, and compassionate people who are striving to save lives and improve the quality of those lives under the guidance of sound ethical principles and informed parental wishes.
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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