Bioethics class visits neonatal facility

[cmotherofpirl]

ACADEMICS
Bioethics class visits neonatal facility

Elyse Graham
Princetonian Staff Writer

Inside the neonatal intensive care unit of a Metuchen hospital, a jungle of machines surrounded a two-hour old baby gasping shallowly. Tubes from one machine sent a steady stream of air pressure down her nasal passages, preventing her tiny airways from collapsing. Intravenous pumps and catheter tubes entered through her belly button, delivering nutrients to her bloodstream and energy pulses to her heart. A screen nearby showed continuous readings of her cardiac function, respiration and oxygen saturation level.

Around her at Saint Peters University Hospital on Friday were 13 Princeton students, members of bioethics professor Peter Singer's "Ethical Choices" freshman seminar.

Singer had brought his students to the ward to show them the living faces of a medical debate featured prominently in his scholarship and his seminar: whether it is ethical to end an infant's life when medical data predict she has a low chance of surviving.

The students, excited as they entered the hospital, turned somber as they walked through the ward. Other infants were similarly surrounded by life support machines, and the philosophical debates previously held in class had become a stunning reality.

"Everyone came in very bouncy and energetic, and I thought, 'Wow, these people have no idea what they're getting into,'" said Jennifer Calise, a young mother cradling her one-year-old daughter, a former ward patient who had come for a checkup. "Now they all look a little shell-shocked."

Born 14 weeks premature, the 2-hour-old infant the class had come upon had a slim chance of surviving, let alone growing up without mental and physical impairments. Because of these defects, Singer argues the infant's parents should be able to decide whether to shut off her life-support machines and end her life. That claim, based on a belief that a young baby is not self-aware, has generated widespread controversy across the world.

Division of Neonatal Medicine Director Dr. Mark Hiatt had led the class to this tiny red infant. Up close, the class could see her small forehead muscles contracted, eyes squeezed shut. As she breathed, her abdomen sucked in and out ferociously.

"This is one of the smallest babies we've ever had," Hiatt said. At nine inches and 365 grams, she could easily fit in the palm of an adult's hand. (A baby in the 50th percentile of births would weigh 960 grams.)

Though he said the infant's fate was dependent on "literally minute-to-minute, hour-to-hour" reevaluations, Hiatt maintained that she was fully human and rejected Singer's view of what makes a baby's life worthy of continuance.

"This is a child. Somebody's daughter," Hiatt said. "Hopefully she'll be with us for many weeks and eventually go home with her mother and father."

But the presence of Singer and his class made things less clear.

"Is it ethical to keep a baby alive without the chances of it being healthy and able to go to public school, whether a special school or not, or whether it would hurt the baby and everyone involved?" Courtney Mazo '08 said on the bus ride to the hospital. "Who makes the decisions to keep going with care, and what do you do if the parents and doctors conflict? And when is it better to refuse care instead of doing everything you can?"

But, she noted, with medical advances, premature infants can live longer. Other questions — such as cost of treatment and quality of life — nevertheless remain.

Hiatt described his struggles with the issue for the class. Once, he said, a family asked him to withhold care for their premature baby because of financial reasons. The father was in graduate school and had a young family already. Hiatt asked them to seek another hospital.

"We [at St. Peter's] don't want to do all this aggressive, heroic intervention unless there's a good possibility that this will be an intact, healthy child," he said. "[But] I could never do anything to terminate a [healthy] life. I became a doctor for the opposite reason."

Hiatt said he would not allow a baby to die by any means except withdrawing care, called passive euthanasia.

"As a society, I don't think we want our doctors to [perform active euthanasia, where the doctor directly ends someone's life]," he added. "I wouldn't do it. I couldn't do it. . . . I'm not an executioner."

Not all students, however, accepted Hiatt's reasoning.

In discussion on the bus ride home, class member Nic Poulos '08 called Hiatt's distinction between active and passive euthanasia "semantics."

"He's enabling the child's death, period," Poulos said. "He didn't say, 'Yes, [my position is] based on guilt, but he did say, 'No, I couldn't do that.'"

Singer played his usual Socratic role in the discussion, speaking up only to inject questions or ask for clarification. When pressed, he agreed with Poulos.

"I don't think there's a distinction between deciding to withdraw life and deciding to actively end it," Singer said. "[Hiatt] also has an attitude that you should try to save every life you can, regardless of circumstances. In the case of the grad student [who asked Hiatt to withdraw care from his baby] . . . it's still a human life, but it's a life that's barely begun. I would have been prepared to agree with the parents."

Singer's has stirred much controversy with these views, with some groups labeling him a "baby-killer." Singer responds by saying that societies throughout history have used selective infanticide for the greater good.

Singer also refuses to equate killing newborns with killing adults, saying newborns are not self-aware and therefore different from adult humans and animals worthy of protection.

Some of Singer's students disagree with these views.

Mazo, whose mother works as a neonatologist, said experience tells her it's "better for families" to make the most of even a brief time together.

Such a time was all too brief for Calise, whom Hiatt introduced to the class as someone "who's been under the anvil."

Calise was forced to confront the viability-of-life issue abruptly in February 2003, when her water broke early and doctors told her the fetus had a low chance of surviving. When Calise gave birth to her first child several days later, the newborn's prognosis was not good.

"What we call viability is 24 weeks," said Dr. Denise Hassinger, who oversees Calise's care. "[Calise's first baby] came out at 23 weeks. And she could move, she could breathe and everything, but it was 23 weeks. So is it a person, is it not a person? There's a lot of legal and ethical issues involved."

Calise had instructed the doctors to resuscitate the baby if it showed any chance of survival, but its premature birth, and a severe prenatal infection, suggested little use in trying to keep the baby alive. The baby, named Simone, died after support was withdrawn.

"[My husband and I] have seen the miracle babies, and everyday we ask ourselves, did we do the right thing?" Calise said.

Calise gave birth again in September 2003 to a baby named Ava. Though her second baby was also premature at 25 weeks, it was relatively healthy otherwise and doctors started care immediately. Calise proudly showed the class her cheerful, healthy daughter.

When Hiatt encouraged students to ask Calise questions, they were hesitant. "I could see with the students, everyone was thinking 'Oh my God, is she going to have a nervous breakdown if I say her first child wasn't a person?'" Calise said later.

After about 30 seconds, the first question came from Faruk Colakoglu '08.

"Are [underdeveloped babies] children?" he asked.

"What makes them a child?" Calise replied. "I mean, is it the fact that they breathe, or is there something else that tells you there's a life?"

[Mateo el Feo]

Wow...good article!

[Birgitta Noel]

That was a good article. I've just been writing on NICU ethics and there are soooo many issues. Not the least of which is just because we have the technology to keep someone alive should we.

I don't think the issue when people withdraw care is whether or not the neonate is a person though. Of course Singer would argue that it is.

Be aware though when you read this that the withdrawing of care is not classified as euthanasia of any sort by the Church when it is overly burdensome or merely prolonging death. The problem with a lot of these cases is that the care should never have been started to begin with.

[Dreamweaver]

I love the ending quote in the article.

What exactly does the guy talk about when he refers to "passive euthanasia"? It is withdrawing of excessive and burdensome care, or withdrawing foods, oxygen, and heat?

[Birgitta Noel]

[quote]"We [at St. Peter's] don't want to do all this aggressive, heroic intervention unless there's a good possibility that this will be an intact, healthy child," he said. "[But] I could never do anything to terminate a [healthy] life. I became a doctor for the opposite reason."

Hiatt said he would not allow a baby to die by any means except withdrawing care, called passive euthanasia.

"As a society, I don't think we want our doctors to [perform active euthanasia, where the doctor directly ends someone's life]," he added. "I wouldn't do it. I couldn't do it. . . . I'm not an executioner."

Not all students, however, accepted Hiatt's reasoning.

In discussion on the bus ride home, class member Nic Poulos '08 called Hiatt's distinction between active and passive euthanasia "semantics."

"He's enabling the child's death, period," Poulos said. "He didn't say, 'Yes, [my position is] based on guilt, but he did say, 'No, I couldn't do that.'"
[/quote]

It's somewhere about 1/2way into the article. He doesn't really articulate what he means, but the students' responses are typical. Withdrawing care does not equal euthanasia and that is what the students are implying.