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5. PREEMIES
How small a baby is too small? Each year, new technologies have been instrumental in keeping alive tiny babies who ten or even five years ago would not have had a chance of survival.
Babies weighing just 500 grams who have developed in utero for just 24 weeks?a full term baby is born at 40 weeks?can live. Today, that weight and that extent of maturity are the rock bottom for survival. Sometimes, though, these tiny babies end up with serious lifelong physical and mental problems. So the question arises whether this small is, in fact, too small. Technology is not helpful if it creates new and more serious problems than it solves.
When a woman goes into labor early, doctors do all they can to stop the baby's premature birth in the hopes that the baby will reach 27 weeks in utero and a more robust weight of 700 or 800 grams.
Dr. K.N. Siva Subramanian, the director of the neonatal intensive care unit (NICU) at Georgetown University Hospital, breaks down the survival figures this way:
Babies who can stay in utero long enough to attain birth weights of 1000 to 3000 grams generally do well.
Those who weigh 700-800 grams at birth now actually can "look great," and this is the result of two interventions?steroids, which induce the maturation of the babies' organs, and surfactant, a lung-coating fluid, that helps prevent the babies' lungs from collapsing. These medicines counter the main problem for tiny preemies?the immaturity of their organs?which is behind their struggle to begin life on their own and breathe.
Babies who weigh less then 700 grams have more problems. 75-80% of them will survive. Of these, 60-75% will be normal. The other 25-30% fall into three groups whose problems range from mild to severe.
Subramanian cautions that it is inappropriate to make decisions and predictions about preemies today on the basis of what happened to comparable preemies 15 or 20 years ago. Today's preemies enjoy the fruits of new medicines and technologies that did not exist for the first surviving sets of premature infants.
Additional Resources
- Time 1990, June 11.
- Newsweek 1988 May 16:62-70.
- Belkin, L. First Do No Harm, chapter titled "Taylor"
- Charon, R. et al., section titled "Emily's Story"
- Mass, Bryn Mawr Alumnae Bulletin, 1996, Spring, 11-14.
- Washingtonian, 1996, October, 74-129.
Aims
Students should understand the following:
- The dramatic impact that technological interventions have had on babies born prematurely
- The ethical issues associated with delivering and saving tiny babies
- Policy debates about preemies among legislators, lobbyists, advocates for the disabled, ethicists, theologians, and others
- Parents' roles in decision making about preemies and the conflicts and disagreements that arise between parents and hospitals
- Factors that increase a woman?s chances for delivering a baby prematurely
- Importance of prenatal care in preventing premature deliveries
Suggested questions for discussion
- Do you know kids who were born prematurely? Were you? Have they or you had physical or mental problems that are directly related to life in the NICU?
- In deciding whether to do everything possible for a preemie, whose interests do you think should be considered first?the baby's, the parents', the siblings', the society's?
- Is all human life equally worth taking heroic measures for or does the expected quality of the life matter?
- One author has labeled the NICU "runaway technology." Do you feel the NICU is serving society? Do its benefits outweigh its risks?
- People, particularly nurses, who work in NICUs often get very attached to the infants, sometimes working overtime with specific babies. What do you imagine could be long-term effects on these caregivers of such heavy personal involvement? If, at the other extreme, hospital staff do not get personally involved, is there a chance that the baby could be "objectified" and then not benefit from all the types of human contact?touch, stroking, hearing voices, making eye contact?that are so crucial in early development?
- Are there differences in the rates of prematurity in different socio-economic populations? In different countries? What do you think causes these differences?
- Do pregnant women have moral obligations not to harm their unborn children? Do some behaviors increase the chance that a baby will be born prematurely? If so, should such behaviors be prohibited?
- Do you expect that babies who end up severely handicapped as a result of their NICU experiences or who end up "captives of medical technology" would be grateful to or angry with the people who saved their lives?
- One critic of the NICU argues that NICUs save a few lives with extravagant use of resources but do nothing to improve the lot for most babies and most mothers. What do you think of this position?
- What do you think NICUs will be like 20 years from now? Will they exist?
- One author writes that babies, being the least "individualized" of all people, have the least personality and the fewest "interests." Considering this, should more or less be done for them than for other individuals in the society?
- In the essay Mass (reference 5 above), technology caused a problem by indicating that something was wrong with the fetus when, in fact, nothing was wrong. How often do technologies create rather than solve problems?
Topics for discussion/written assessment
- When there is a disagreement between the parents and the doctors, whose views should prevail? Defend your answer, making sure to include how the baby?s interests can/should be protected.
- Since prenatal care is so important in a baby?s life, and autonomy is such an important concept in American law, how should a mother?s behaviors (i.e. substance abuse, smoking, eating habits, etc.) be measured against the potential harms they can do to her child?
- What criteria are used to decide whether, and what kind of, interventions should be used on premature babies?
- If the hospital?s policy regarding preemies conflicts with the parents? decision and the baby survives but is severely disabled, who is financially responsible for the lifetime care of the child? Why?
Question for further investigation
- Compare and contrast the treatments available to, and the probable outcomes for, preemies today with those that were standard twenty years ago.
- Infant incubators were first developed in France in the 1880s and were introduced into the United States around 1900. In the first half of this century, incubator baby "shows" were a hit on Coney Island. From these early sensationalist beginnings, the NICU eventually arose. Find out more about the specific technologies that led to and are today part of NICUs.
Topics for teacher preparation
- Biology of prematurity
- Fetal development
- Prognosis for preemies
- Changes in the last 20 years with respect to survival, including the technology
- The vulnerability of teens to delivering prematurely
- The effects of prenatal care on reducing (but not eliminating) premature births
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