ETHICS IN MEDICINE University of Washington School of Medicine

Neonatal ICU Issues

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What is the primary justification for the existence of neonatal intensive care units?
Is there an increased morbidity associated with higher survival rates?
Do survivors and families think that aggressive care for very low birthweight is good?
Is it possible to predict which infants will not survive without aggressive medical/surgical care in the neonatal period?
Who is the decision-maker regarding the nature of medical care administered to a newborn infant?
What is the accepted legal and ethical basis for decision-making regarding the nature of medical care in the newborn infant?

The evolution of aggressive treatment of the newborn infant over the past 35 years has been associated with a dramatic reduction in mortality for virtually all major disease categories in the newborn period. Such care is costly; often causes suffering; and sometimes can result in considerable long-term morbidity.

The following quotes provide a perspective:

"Neonatal intensive care is responsible for the survival of a significant number of infants who formerly would not have survived. This increased survival has been accomplished with an acceptable level of burden and without substantially increasing the population of handicapped children."
- A proponent
"Neonatal intensive is a good example of medicine out of control. There is inappropriate use of technology by health care professional who are out of touch with patients and their families. The benefits of increases survival of high risk infants are outweighed by the associated burdens."
- An opponent

Case 1

Case 2

What is the primary justification for the existence of neonatal intensive care units?

Increased survival in all birthweight categories from extreme prematurity to term infants with complex congenital anomalies.

Low Birthweight Survival (%)

Est. G.A.* Birthweight (gm) Before 1970 1980 1990 1997

23-24 wk. 500-599
Less

than

10 %

Survival

35

55
22 29

24-25 wk. 600-699 47 61

25-26 wk. 700-799 89 85

26-27 wk. 800-899 80 81

900-999 90 90

(University of Washington NICU Data Base)
*Gest Age in Weeks Added Arbitrarily Assuming Infants +- AGA at Birth

Infant Mortality by Selected Causes
(Deaths per 100,000 live births)

1970 1984 1997

Congenital Anomalies 302 228 156

Respiratory Distress Syndrome 156
1979) 103 32

Intrauterine Hypoxia (Birth Asphyxia) 253 26 11

Disorders relating to short gestation and low birthweight 234 100
(1979) 96

Data source: National Center for Health Statistics

Is there an increased morbidity associated with higher survival rates?

Long-term follow up studies of NICU very low birthweight survivors demonstrate that while most are normal, there are significant numbers of children with both minor and major handicapping conditions.

Data pertaining to the long-term impact of the survival of infants with complex congenital anomalies are less plentiful, but indicate an increased number of handicapped individuals who survive the neonatal/infancy period following successful life-prolonging treatment.

Do survivors and families think that aggressive care for very low birthweight is good?

A recent assessment of the attitudes of a large group of adolescents, former extra-low birthweight infants, demonstrated that their view of their quality of life was "quite satisfactory." Indeed, when compared to a comparable age group of normal controls there were few difference between the two groups in their perception of their quality of life.

Is it possible to predict which infants will not survive without aggressive medical/surgical care in the neonatal period?

Extremely immature infants (gestational age at birth of less than 25 weeks) and/or infants with congenital anomalies that involve vital organs (for example, intestinal atresia, renal agenesis, pulmonary hypoplasia, hypoplastic left heart) have 100% mortality without aggressive intervention.

However, a much larger group of infants with serious life-threatening conditions may not be so vulnerable to death as they are to severe morbidity in the absence of intervention. It is virtually impossible to predict which infants in the latter group will not survive without support; and which will survive but with more morbidity/suffering than they would have experience had there been aggressive intervention.

Who is the decision-maker regarding the nature of medical care administered to a newborn infant?

The biological parents (or parent) have authority regarding the decisions for their child. Notably, this is the case regardless of the parents' age, unless the parents are declared not competent or otherwise unfit to serve as the child's proxy (see also Parental Decision Making).

What is the accepted legal and ethical basis for decision-making regarding the nature of medical care in the newborn infant?

The child's best interest is legally and ethically primary and should be weighed over the family's well-being or societal concerns. However, there is considerable discussion in the literature about the need to include the family's interests when making life and death decisions regarding severely compromised infants who will be a significant burden. Societal concerns about excessive cost for aggressive care need to be addressed at the policy level, rather than on an individual or case-by-case basis.

Case 1 | Case 2
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Core clerkship material for: Obstetrics and Gynecology

David E. Woodrum, MD
Professor, Neonatal and Respiratory Diseases, Pediatrics
Faculty Associate, Medical History and Ethics, University of Washington

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Last date modified: April 11, 2008