Rationing Care at the Beginning of Life?

UK doctors refuse to resuscitate baby born at 21 weeks, sparking debate.

ByABC News
October 27, 2009, 5:35 PM

Oct. 29, 2009— -- In the course of the debate over health care reform, some of the political rhetoric has focused on "rationing" and the idea of how much money can or should be spent on someone at the end of his or her life. But as care evolves, similar debates may someday surround how much can be spent at life's beginning.

Few cases illustrate this as starkly as a baby born prematurely at 21 weeks and five days in Britain last month, who died as doctors declined to resuscitate him. Sarah Capewell, the mother of the deceased infant, started Justice for Jayden, a bid to change the guidelines for early preterm babies in the United Kingdom.

The doctors in the case were following guidelines that establish viability for babies in the U.K. at 22 weeks. The case has been seized upon by some opponents of nationalized health care in the United States as a reason to avoid it, sparking fears that inevitably "rationing" will mean rationing at both the end and the beginning of life.

Capewell did not respond to a request for comment from ABC News.

To be sure, doctors contacted by ABC News were unanimous in their assessment that Jayden would almost certainly not have survived, even with resuscitation.

"The probability of survival at 22 weeks is effectively zero," said Dr. F. Sessions Cole, director of the division of newborn medicine at Washington University in St. Louis.

The youngest surviving baby born in the United States was Amillia Taylor, born in 2006 after 21 weeks and six days, but as it was noted at the time, because she was conceived via in vitro fertilization, her actual age was closer to 23 weeks.

But doctors say making determinations of age and viability are not an exact science. Most babies are born naturally, and so, an exact determination of fetal age often cannot be made, and age does not necessarily tell a doctor exactly how high-functioning a baby will be, particularly since only a few weeks separate a baby who cannot breathe on his or her own from one who can.

"When you have a regular pregnancy, you don't know exactly what the implantation [date] is," said Dr. Ian Holzman, chief of the division of newborn medicine at the Mount Sinai School of Medicine. "It's always an issue when we counsel patients prenatally. Unless we know for sure the date of implantation, the baby may be a little more mature than we think."

"Size is part of the issue here, and speed of development," said Arthur Caplan, director of the center for bioethics at the University of Pennsylvania.

At 21 weeks, he said, a baby usually doesn't have much in the way of lungs, and, therefore, cannot breathe even with assistance from a ventilator.

"There's no rule here about 21 weeks, 22 weeks, 23 weeks, you've got to take a look at the baby," he said.