Muraskas et al. and Hefferman and Heilig present the
painfully elusive ethical questions regarding decisionmaking
in the care of the extremely low birth weight (ELBW) infants
in the intensive care nursery. At what gestation or size
do we resuscitate? Can we stop resuscitation after we have
started? How much money is too much to spend? Is the distress
of the parents of the ELBW infant, the anguish of their
caregivers, and the moral and ethical uncertainty of the
approach to these infants too much to pay? Who speaks for
the neonate: the parent, nurse, attorney, or physician?
Ideally these questions should have been answered 30 years
ago when modern neonatology embarked on a journey from
where it could not return. A new breed of physician, called
“neonatologist,” seduced by the high-tech lure
and the promise of saving lives previously unsavable pioneered
a lucrative and life-saving technological revolution in
the care of premature newborns. This rapid advancement
in neonatology occurred a few years after the death of
a premature infant named Patrick Kennedy in 1963. While
the country mourned, medical scientists vowed that this
would not happen again. First continuous positive airway
pressure, then mechanical ventilation, changed medical
care of premature newborns forever. It began an era of
euphoria and excitement. Neonatologists raced to push to
the edge of newborn viability. What was the youngest salvageable
gestational age? What was the smallest that could be saved?
Yes, we dreamed, and still do dream of artificial placentas.
Ethical questions took a back seat in the search for the edge because the waters were uncharted and the tough questions could not be answered without experience. What was to be the cost in dollars and in anguish to save the Patrick Kennedys of the world? Triumphs led to grave concerns as we approached the edge. However, no advancement in neonatology has ever changed the ultimate questions.