The neonate: a community's moral compass?

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There is convincing evidence that, in many communities, newborns do not have the same moral status as older children and adults. North American ethicists assessed the relative moral value of preterm neonates by asking physicians and students of anthropology, bioethics, law and medicine to prioritise eight hypothetical patients who needed intubation and intensive care at the same time. The extremely preterm neonate came seventh, above the demented 80-year-old with a stroke, but after the 35-year-old with brain cancer who had a 5% chance of survival and 100% of handicap after surgery, chemo- and radiotherapy.1 Is this because there is a general ignorance as to the outcomes of neonatal intensive care? The chance of disability-free survival for extremely preterm infants continues to improve and neonatal intensive care compares favourably with adult intensive care regarding cost-effectiveness.2 Although the extremely premature neonate is an important part of neonatal care, there are many mature babies admitted to the neonatal intensive care unit with a very high survival rate and excellent outcomes. Even the way we refer to some babies, such as babies conceived after prolonged infertility, as ‘precious’ implicitly devalues other babies.1

Why do we undervalue newborns morally? Some argue that a newborn is not yet a ‘person’, a complicated construct that begs the question of when the baby becomes a person and what exactly constitutes becoming and ceasing to be a person. It is possible that because newborns have historically been very vulnerable, with mortality in the neonatal period higher than for any other age-bracket, our undervaluing of babies may be a cultural and possibly an evolutionary protective adaptation.

The way the sick and dying neonate is viewed differs within communities and cultures. In Western countries, we agonise about the ethics of limitation and withdrawal of neonatal intensive care.3 North American ethicists argue that we subject neonatal intensive care to greater scrutiny and hold neonatal care to higher standards of justification than intensive care for older children and certainly for the elderly,1 even though neonatal intensive care has been shown to be cost-effective.2 In developing countries, in contrast, the problem is one of equity. Almost 99% of neonatal deaths occur in developing countries, mostly in homes in the community, not in hospital. In many low-income countries, newborns do not have access to even the most basic low-technology means of survival, such as basic resuscitation to prevent birth asphyxia,4 access to kangaroo care5 (see Fig. 1) and community access to health care.6 With this disparity in mortality rates, there is a different perspective on acceptance of death, but there is little literature on how families are best supported through this time in developed countries let alone in developing countries.7 Because a poor outcome is rare in developed countries, families struggle with accepting it and frequently seek someone to blame, while on the other hand staff involved in antenatal care rarely discuss adverse events, giving parents the false perception that interventions are unnecessary and nothing bad will ever happen.

Figure 1.

Kangaroo care (photograph courtesy of Professor Heather Jeffery).

At the United Nations Millennium Summit in 2000, world leaders agreed on goals including reducing deaths of children under 5 years old by two-thirds. Ironically, as immunisation levels improve globally and the absolute numbers of deaths fall, the proportion of neonatal deaths has increased to over 40% of all under-5 deaths.8 In 2005, the United Nations, World Health Organization and partners formed the Partnership for Maternal, Newborn and Child Health to focus advocacy, fundraising and research to reduce neonatal deaths. The good news is that the estimated global annual total of deaths fell from 4.6 million in 1990 to 3.3 million in 2009, and the global neonatal mortality rate (NMR) by 28% from 33.2 to 23.9 deaths per 1000 live births. The challenging news is that in Africa, the NMR only dropped from 43.6 to 35.9, whereas in some areas neonatal mortality was halved. An important component of reducing neonatal mortality is accurate classification of neonatal deaths to identify underlying causes where interventions may be of benefit.

Although many neonatal interventions derive in part from adult medicine, neonatology is now providing evidence for other areas of health care. From neonatal studies, the importance of oxygen toxicity is now being considered by adult cardiologists in adults after myocardial infarction where oxygen therapy used to be a mainstay treatment. Barker's hypothesis has important implications for neonates and, therefore, ultimately for paediatricians and adult physicians. Paediatricians need to advocate for neonates, whose moral status is frequently and perplexingly under-valued given that the first weeks and months of life can have an enormous impact on their long term neurological and cardiovascular outcome. Many of the issues raised in this editorial are discussed and developed in the articles of this special issue of the Journal of Paediatrics and Child Health, edited by Alison Kent, and is a small attempt to redress the balance and increase knowledge and interest in neonatal care.

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