Published online May 2, 2005
PEDIATRICS
Vol. 115
No. 5
May 2005, pp.
1451
(doi:10.1542/peds.2005-0216)
Russian Roulette: Final 2
William B. Weil, MD
Professor Emeritus
Pediatrics and Human Development
Michigan State University
East Lansing, MI 48824
To the Editor.—
William A. Silverman died (December 16, 2004) before his letter to the editor, "Russian Roulette in the Delivery Room,"1 was published in the January 2005 issue of Pediatrics. When he wrote that letter in September 2004, he asked me to write some comments when it was published, as he had done in the past. This letter was written in response to that request.
Dr Silverman, one of the world's leading neonatologists for over 50 years, was also one of the specialty's most severe critics. He frequently wrote about much-heralded treatments and procedures, often ones he himself had once adopted, but that were subsequently found to be deleterious to these infants. Such experiences led him to become an ardent supporter of documented and scientifically sound clinical trials before adoption of often well-intended, innovative interventions. Thus, his concern about the use of high-technology procedures and medications that increased survival but may have disproportionately increased the occurrence of significant disability was related to his commentary "Compassion or Opportunism?" published in the February 2004 issue of Pediatrics.2
However, his comments in "Russian Roulette in the Delivery Room"1 were related to his long-term dedication to sustaining the rights of parents to make decisions for their newly born infants. The incident that triggered this response was the birth of an infant at 23 weeks' gestation who was resuscitated in the delivery room, apparently in contradiction to the parents' desire that no such treatment be given. A long legal battle, in which the parents' position was originally upheld, ended by being overturned later by the Texas Supreme Court,3 which held that resuscitation in the delivery room was appropriate. Subsequently, John A. Robertson supported the Supreme Court's decision in an article in The Hastings Center Report.4
Dr Silverman saw this position as denying the inherent right of parents to determine the care of their own infant and forcing parents to accept an outcome with much worse odds than in Russian roulette. Amplifying Dr Silverman's appropriate concerns, data continue to demonstrate that at 23 weeks' gestation, infants are at the borderline of viability, and among the relatively few survivors, long-term disability is frequent.5,6 Thus, the likelihood of a normal, healthy survivor is very low. As a result, there are some neonatologists who would abide by the delivery-room decisions of parents for infants of this gestational age. Whether this attitude should also apply to infants born at 24, 25, or 26 weeks' gestation should be discussed broadly.
However, as Robertson indicates, even if one were to accept parental decision-making for these very immature infants, he states it would only be after initial resuscitation efforts had been conducted in the delivery room. It was this aspect of Robertson's position that was especially disturbing to Dr Silverman. Robertson indicates that he would favor immediate resuscitation for all infants born alive and then defer assessment until after some degree of stabilization had occurred. He recognizes that such a practice would pose additional burdens on parents, but what he does not mention is that one of the difficulties that arises from such a practice is that the infant's prognosis in terms of ultimate survival and disability is not likely to be any clearer after such a limited time interval than it is at the time of birth. It would seem, therefore, that parental decision-making at the time of birth for extremely immature infants should be the determining factor for the care of such infants, as Dr Silverman recommended.
REFERENCES
- Silverman W. Russian roulette in the delivery room [letter].
Pediatrics. 2005;115
:192
–193[Free Full Text]
- Silverman W. Compassion or opportunism [commentary]?
Pediatrics. 2004;113
:402
–403[Free Full Text]
- Miller v HCA, Inc. 118 S.W.3d 758 (Tex 2003)
- Robertson JA. Extreme prematurity and parental rights after Baby Doe.
Hastings Cent Rep. 2004;34
:32
–39[Medline]
- Marlow N, Wolke D, Bracewell MA, Samara M; EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth.
N Engl J Med. 2005;352
:9
–19[Abstract/Free Full Text]
- Vohr B, Allen M. Extreme prematurity—the continuing dilemma.
N Engl J Med. 2005;352
:71
–72[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
