Dr John Lantos1
1Childeren’s Mercy Hospital, Kansas City, Mo, United States
Survival rates for babies born at 22 and 23 weeks are steadily improving at centers that offer active treatment to these babies. For example, survival rates for these babies are about 30% in Japan, Sweden, Iowa, and Cologne. At these centers, survivors have outcomes that were similar to outcomes for babies born at 23 and 24 weeks of gestation. Most survivors have no serious neurodevelopmental impairment (NDI) Nevertheless, many centers do not offer active treatment to babies at this gestational age. One might expect these results to generate excitement, emulation, and replication. Instead, the results are misrepresented by professional societies. For example, One might expect that such a startling medical breakthrough would stimulate excitement, admiration, emulation, and research. Oddly, it seems to have generated none of those things. Instead, key professional societies have either ignored or misrepresented the outcome data. For example, a 2016 statement by the American College of Obstetrics and Gynecology (ACOG) and the Society for Maternal and Fetal Medicine (SMFM) wrote that “delivery before 23 weeks of gestation typically results in neonatal death (5–6% survival) and among rare survivors, significant morbidity is universal (98–100%).” In this paper, I speculate about three reasons why many centers seem loath to offer a treatment that could save thousands of lives. First, people overestimate both mortality rates and the rates of NDI among survivors, based on experiences in which such babies received inadequate treatment. Second, successful treatment of extremely premature babies requires an institutional commitment and cooperation between maternal-fetal medicine and neonatology. Finally, some people worry that survival of such tiny babies might lead to tighter restrictions on legal abortion at the end of the second trimester. In conclusion, I will recommend careful study of outcomes using best practices for both shared-decision making and neonatal intensive care.
John Lantos, MD, is Professor of Pediatrics at University of Missouri in Kansas City and the founding director of the Children’s Mercy Hospital Bioethics Center. Prior to moving to Kansas City, he was a Professor of Pediatrics, Chief of General Pediatrics, and Associate Director of the MacLean Center at The University of Chicago. He has served President the American Society of Bioethics and Humanities as well as of the American Society of Law, Medicine, and Ethics.
From Kansas City, he directs an innovative, on-line program that is training a new generation of scholars from around the world in pediatric bioethics.