As any discussion about "heroic measures" would be, this is likely to be thorny. (I'm arbitrarily assigning the special measures needed to ensure survival of a super-preemie as "heroic" for discussion purposes)

It's inconvenient in an academic argument to admit anecdotal incidents, because it then injects a level of emotion into the debate that skews the positions of those arguing. So, the experiences of your friends who had super-preemies who survived to become happy, healthy children will necessarily colour your position, and proper thing. The entirety of human existence is anecdotal, after all. Having said that ...

As in the Latimer case, "quality of life" is a consideration here, and what follows hot on its heels is a discussion about who determines "quality of life" and what standards they use. It's like good art: I may not be able to define it, but I know it when I see it.

And, like good art, it's a very subjective thing. Hell, I know good people who toil away at jobs they don't enjoy, hanging on for a pension even though they hate to wake up in the morning. Faced with that quality of life, I might put a bullet in my brain; they seem to get along just fine.

On the other hand, a good friend of mine, Darcy MacPherson, was born with what by any measure would be termed "disabling cerebral palsy" - he is confined to a wheelchair, is very difficult to understand when he speaks, and has required decades of special care from his parents, siblings and a host of medical professionals which would number in the hundreds, if not thousands. If you want to argue he has had no quality of life and no chance of becoming a contributing member of society, you'll have to call him at his law firm in Toronto.

If I read the percentages right from the article, the survival rate for children born that prematurely is 25%, not the 75% you posit. So, in numerical terms, of 100 babies born at 23 weeks:

75 die before they return home
11 have severe or moderate disabling conditions
8 have mild disabilities
3 have disabling cerebral palsy
5 have little or no known disablity

(I was baffled about the numbers not adding up, until I concluded that the children labelled with "disabling cerebral palsy" were accounted for twice)

Here's the thing, though - medicine isn't a zero sum game. The mammoth resources you subtract from the system to rescusitate and nurture a super-preemie come from somewhere else in the system. "Heroic measures" are about as expensive as it gets in the medical world, and if we assume finite resources, that means somebody isn't getting served. Hopefully, the first off the table are the breast enhancement cases or the nose jobs or other unnecessary medical issues. But at some point, you're taking money and resources from other patients who are every bit as deserving as hopeful, distraught parents. And when your chances of unqualified success - even with heroic measures - are down to 5%, at what point do you decide to redirect those resources toward a problem you have a better chance of solving?

You have corrected my most basic error - precaffinated me reversed the 75%. I will note it but I will still leave the error that as it does that matter as nature is taking care of that percentage - one way or another those kids do not make it despite a short term intervention. No medical assistance makes a difference.<p>That being said, what you call "emotion" is actually morality to many. "Quality of life" is a misnomer to those who feel life is actually in itself an absolute. This question reminded me of George Grant's classes in the 80s at Dal and his theme of not letting technology guide your morality (as opposed to your values). <p>And I do not know whether "mammoth costs" actually apply compared to, say, a senior citizen's heart condiction. There many not actually be too much by the way of physical intervention and surgery or high cost drugs involved as opposed to incubators and time.

To add to my public education on this, here is a bill that was before the US Congress in October 2003 on preemie birth costs which includes interesting stats in its preamble. These facts are set out, the second of which I find hard to believe as "an average" as stated:<blockquote class="smalltext">The estimated charges for hospital stays for infants with any diagnosis of prematurity/low birthweight were $11,900,000,000 in 2000. The average lifetime medical costs of a premature baby are conservatively estimated at $500,000.</blockquote>

...and a medical abstract from 1994 showing the following morality rates for preemies:<blockquote class="smalltext">Of 1024 births occurring between 23 and 28 weeks GA [Ed.: "gestational age"], 911 were live born. The mortality rate decreased with increasing GA: 84% at 23 weeks; 57% at 24 weeks; 45% at 25 weeks; 37% at 26 weeks; 23% at 27 weeks; and 13% at 28 weeks GA</blockquote>Interesting to note that this weeks <i>New England Journal of Medicine</i> report relied upon by the CBC for its article uses data from Ireland and the UK from 1995. Does tha make a difference? It would appear that there was a massive difference between 23 and 24 weeks ten years ago. Is there the same difference now?

I imagine that in ten years, considerable progress in resuscitation has been made, so I'm not surprised by a ten percent improvement in mortality rates. Nor am I particularly taken aback by the $500,000 average when it comes to estimate medical costs for a super-premie. If anything, it seems surprisingly low to me.

In 1983, our second daughter was born after 40-odd hours of labour. She was born with serious A-V malformation and was not given much chance of living - and had she lived, the surgeries and primary medical care (without even considering the long-term medical support) would have been a staggering figure. As it is, after living for about 36 hours, she passed away. At our request, heroic measures had not been initiated.

Still, after only 36 hours, and without heroic measures, the primary medical costs were estimated at close to $50,000. For that she received first-class medical care, even though everyone knew it would not be enough to save her.

Any time I hear someone crap all over socialized medicine, I think back to that weekend - and what its impact would have been to a young family living in a country less compassionate than Canada.

[i]The average lifetime medical costs of a premature baby are conservatively estimated at $500,000.[/i]

I wonder what the average lifetime costs of a standard term baby are in whatever jurisdiction this refers to are. A dollar figure means nothing if it has no comparable.

Thanks for that, Nils. We had a similar experience with my oldest neice which also confirms my trust in socialized medicine. I think, though, to my mind, once you get to the, say, the 60% change viable life without pain threshold, I am having a hard time understanding how proceeding with normal processes of providing health care should be provided without question. Extrapolating from the numbers above, that is probably now the 24 week stage. And even that is arbitrary when you think of it. It just strikes me, given the number of disabled from birth in my family, we are relying on science and a certain level comfort of convenience (hard to put it otherwise) to be disuaded from the extra cost of dealing with these humans' entry into the world. You know, if it is about making value decisions opposed to moral ones, I am inclined to put money there compared to, say, the cost of keeping smokers or speeders going. Is that unfair or unwise?

One other thing, Nils. Remember that the 84% to 75% mortality for 23 week olds are both ten year old numbers, are they not? in 2004 as opposed to 1995 we may now be well under that. This change in technology illustrates the problem with the techologically-based quality of life value-based evaluation of viability as opposed to the moralty-based life as life determination. Both are independent of the economic assessment of the same question.

I don't have a problem with morality-based decisions ... as long as it's my morality. But aren't we all like that? Our moral codes may all be based on similar principles, but each of us draws our own lines.

When an anti-choice activist says that abortion should be illegal "except in cases of incest or rape" ... they've drawn a line that others of their ilk may not agree with. A doctor who deals with the practical issues of "quality of life" may have an entirely different perspective than the mother of super-premie who - unexpectedly and tragically - now has to face not just the possible death of the child she has been expecting, but also the corresponding death of all those dreams of a bright future that were conceived with the child and have grown in the womb along with it.

(That, of course, is the hardest part. To be abruptly ripped away from that hope, those warm dreams of kindergarten first days, soccer games, high school graduations, first boyfriends, family Christmases, college dorm rooms, thrown bouquets and having your grandchild grasp your finger is terribly, terribly wrenching in every way possible. There's a reason that one of the first stages of grief is denial.)

Can we save them all? No. We know we can't. Do we focus our efforts on those with the best chance of surviving? That seems rational and, yes, moral to me. And more than that, it seems "natural" ... in the way that almost all mothers in the natural world will expend more effort on the babies most likely to survive.

It is a more difficult question I think, though I agree with what you have written. Making a determination based on likelihood of disability rather than existence is balancing of capacity which begs the question what we consider human to be. That is when values fail as does the concept "one's own morality", just another way of saying "owns own values". Underlying values must be some basic morality against which individual value choices are made. <p>I think what disturbed me about the original discussion in the CBC piece was not the percentages at all but the idea that gradations of disability at birth should receive gradations of intervention. That is the "quality of life" argument which is not a matter of practicality but, I'd say, really one of morality which guides the given practice. If the disable child is considered an outcome which is not normal, then is that person being considered fully human? I know this is close to the anti-abortion arguement (which is not a problem in itself) but let's stick to the child which has been born.

Al, I think you should more clearly define what you mean by "morality" or "morals" and what you mean by "values". I know you have that George Grant thing going on about the difference between morals and values. I think I understand the distinction you're drawing there. But you are hinting that your idea of "morality" is absolute which I have contended is not possible. Morals are about individual choices and are merely human creations. Ethics govern interpersonal relationships and are a much better tool for talking about things that most people would assign to "morality". Neither, to my mind, are absolute.

Thank you Hans for a favourite diregression on terminology which I pick up without real reference to the above other than to say that I am trying to assert it in the above, however successfully.<p>If morality and value are to be useful as terms they have to be distinguishable. I do not think that a "moral" can be a personal choice and I do not think anything other than an individual can "value". I think a very easy principle of universal morality is that life is sacred. If you do not think it is you are either immoral, like a killer, or you are amoral in that you do not believe in morals at all, only values. An equivalent value is that I respect useful life or I respect independent life. These become by necessity partial interests comapred to the moral assertion of the simple absolute worth of life. People can have morals and still have values as moral s tend to be standards at the constitutional or Ten Commandments highish level. They cannot, however, be compromised by the particular application.<p>Values are your operational wiggle room within the moral. When values, however, replace morality, that is relativism - that everything takes into account other interests to some degree or another and that everything can be compromised to account for another value. It should give anyone a sore tooth to hear the phrases "moral relativism" or "moral values" as neither are properly moral.<p>One can properly say "my morality" in the sense of the moral precepts that one acknowledges and one can also speak of universal morality as there are some things general to all moral schemes. But personal morality, as opposed to personal experience of a morality, is an oxymoron. Ethics, as you say, are the application of either morality or values in a relationship.

Hello there everyone,
I don't know anyone here but I was surfing the web and found this forum and thought I would comment.

I am not going to argue values or morals but rather look at the big picture.

Keep in mind that I am not trying to sound heartless, I am just keeping to the facts.

First off, I think it should be a family choice. Remember that if you are having a pre-mature child, something wrong happened somewhere. This doesn't happen every time to everyone. What are your options? You can draw the situation out longer for a child who, if under 23 weeks, has a 75% chance of dying anyway. And if he/she is lucky enough to even be born, their chances of have a normal life is 20%, or 5 in 100 looking at it from a before death point of view. Doctors, incubators, nurses, etc. will be tied up for hours because they will be fighting the odds to save your child.

I am not saying that there is not hope or that we should not try something, but I think that there has to be a point where we draw the line. What about 20 weeks? 14 weeks? Just because there is a percentage of hope, it doesn't mean that we should deplete our resources.

Also I argue that although the disabled are equal in my mind, if you have the choice of having a child born healthy or with a serious disability, what would you pick?

I think that we have to have points where we can optimize our resources and this seems like a great example of using statistics and compassion in picking a line that is reasonable. Again I refer back to my point that pre-mature children are NOT the norm and something tragic must have happened. In any pre-mature child case, I would say first do what is best for the mother, do some initial probing as to what can be done for the child, and if very little can be done, ask the parents and explain fully the situation.

I can sympathize with Nils and his situation. I think the best way to get an event like this behind you is to re-coup and maybe try having a child again at a later date and hope that conditions and circumstances are better. I'm not saying everything happens for a reason but sometimes you have to do what is best for everyone in a situation and try not to fight the odds simply for fighting the odds sake.

5 to 100 may sound like good odds in respect to say winning the lottery, but if someone gave me 5 to 100 odds of winning the lottery with the other 95 to 100 odds being having a child who is either dead or seriously disabled, I wouldn't buy a ticket.

I appreciate your compassion, Kirk (and yours, Alan), and it's well-placed. But it's been 21 years, our third daughter is in her third year of Honours English, and our perspective on the tragedy is much broader now than it was. I only injected that fact into the discussion to illustrate that - when it comes to these issues - I have some solid ground under me. I've thought them through.

Alan, I couldn't agree more (cue the Four Horsemen) when you agonize that children who are not "normal" are considered less than human. It's (and here, we come full circle) a thorny issue - as is any when we essentially engage in "before the fact triage". If failing to intervene assures death, that clearly devalues the potential life in question - based only upon a presupposition of an outcome and a judgement of the relative merits of that outcome.

And yet, we engage in triage all the time - in emergency wards, on battlefields, and in our daily lives (on a less dramatic scale). How is this so very different?

Triage is supposed to be an exception - an approach during crisis - but, as you say, its risk and cost-benefit analysis has pervaded thinking along with the importance of capacity. I think it is an erosion that is at the core of the problem of modernity and dehumanization. You can turn the question around and consider how many principles, if any, are left to be actually included in an actual morality? I think there are plenty but we are no longer encouraged to recognize them due, on one hand, to political correctness claims and, on the other, usurpation by "family values" politicians - all coated with a great big helping of intoxication by novelty. We are all jaded and perhaps even deaf to it.<p>I think one of the reasons we are seeing the outpouring in reaction to the tsunami is the pent up desire to actually do something actually good in the absolute moral sense of the good. I still have some sense of its connection to the Diana outpouring without a good sense of how.

Tough cases make bad law in part because it's hard to extract a decent moral principle from them. In fact, this latest wave of technocratic babble about survival etc. sometimes makes me think of Huxley's Brave New World. And invoking nature just doesn't help. We don't live in a state of nature and many would say that this is the very thing in fact that makes us human beings. On the other hand, there's an argument among utilitarians and postmodernists of various flavours linking morality (and even values) with fascism and/or totalitarianism which I don't really buy but which I have to mention because I know about it. The long and the short is that I think ur-fascism lies elsewhere. So, the upshot of my latest thoughts on the matter (it's something that is of special interest to me) is that lately I've started to think that sometimes decisions have to be made for reasons other than expedience or a collective sort of group 'interest'. And at the very least you may need to justify the concept and practical exercise of moral relativism itself -- by saying that it is 'best' or 'good in itself' and that the practice of, for instance, free speech (which is a natural corollary to this kind of utilitarian 'moral' order) is good no matter what. I like freedom and think it's a good thing so I am sympathetic to this kind of project. But, I have to say that the latest trend towards total 'rationality' with respect to moral decisions especially in situations involving things like euthanasia kind of make my stomach turn. In fact, I find it kind of astounding that we now think that it's okay to bump off (old or sick) people for their (or more likely our) own good. Anyway... gotta go.

Al, I am not going to speak at length but I think the guidelines are very justified. I value human life to the fullest and I believe we can't supercede our bounds. The monetary cost is one thing, the human and medical cost is gigantic. As a physician who works with children and who sees the tragic aftermath of the very few who do survive, I think it is important that we recognize the limitations of medical science. I recognize your personal experience is clouding this (but whereas you say the babies you know were days from 23 weeks --- I think that they were probably a few weeks and a few days from 23 weeks as there are two ways of counting foetus' age by gestational age and from the Last Menstrual Period which adds on a few weeks). Anyway, an interesting discussion, and I am very very glad I don't have to been in the Neonatal ICU. Al, I think that if you spent some time in a Neonatal ICU your thinking would change dramatically.

To me the real problem isn't so much the having of values or morals, but the application of those values or morals. Because even if you can agree to a moral principle (either because people assume it as a 'real' and objective suprahuman aspect of existence -- morals--or because they institute it as something they agree to abide by personally --values) its application is another matter entirely. If we say we value life (let's say especially human life because you don't want to include things like flatworms or lice necessarily especially if you're going to invoke grand concepts) then you have to say "okay, is this person human?" Let's say that a human life or persons are given this special moral status. Is a baby who has no brain at all a person? Is a zygote then a person? I'm going to say no. I think consciousness defines personhood. Here is another problem: if you say that we will do anything to rescue a premature baby and it's very expensive and it fails, then sometimes that failure goes towards a success later on, so it's not an absolute loss because something is learned. But then, are we experimenting on human beings? At what point does it cease being treatment and start being an unforgiveable ordeal? We should think about this carefully because ultimately we may be able to rescue all fetuses (or almost all) and maybe even gestate them outside wombs and stuff like that without making any sacrifices involving disabilities etc.. This idea might bother some people because it seems kind of freakish. It doesn't particularly bother me. When I referred to Brave New World, I was really only thinking about the complete absence of morality in that novel.

So let's say we want to move beyond interests to discuss this issue, that is, move away from 'values': The question is, what are the moral grounds on which we decide to intervene? Is it because the parents want us to intervene(is desire then the justification)? That is, are we doing it in the interests of the parents (because then it doesn't count as 'moral' in the sense that Alan is talking about if I understand him correctly). It's possible that some principle motivates us. Is the principle of human life and its sacredness part of our motivation? I would say no because human life begins with consciousness. Maybe we do it for another reason. If it's a moral reason maybe it should be the principle of doing no harm. It's the doctor's duty to do all he can for his patients and his future patients.

I think it's really a tricky question. It's one that can't be treated lightly. Also we should consider that if we say no now to heroic efforts, we might be saying no a lot of miraculous scientific breakthroughs in the future and a lot of sacred life-saving. Anyway, good topic, Alan, as usual.

Thanks Marcia and Lisa and all the others. It is a 24 weeker I am mainly thinking of but was not and am not neo-natal ICU person so have that other experience. This is all reminding me of a pal who is on a university board ethics committee and an interesting exercise in wondering how being in that position might feel.<p>Lisa, I was thinking about the possibility in a few decades of the artificial womb myself and, if one is the bleieve Grant's thinking, it should be neutral, that morality cannot be defined by technological capacity. There has to be, however, a corresponding sense of loss that recognzes our incapacity - in this case to get preemies to viability - if we are going to sustain a morality at all. Morality will not get you to perfection in that sense. The value system appears to promise more of that. I do not know if I agree in large part with George Grant's thinking, even though his classes were very compelling, but this one, the integrity of morality as a justification in itself has always stuck with me.

I guess for a litle background I should say that I am 21 and in my 3rd year of computer engineering, I'm not a doctor or a lawyer. But I think it only makes sense to have statisicly influenced gudielines to use resources correctly. I think only chaos will ensue from having some sort of magic 8 ball where we guess whether or not a child can make it because they are only 3 weeks from the deadline. *Shake Shake Shake* Yes, we'll devote 7 doctors to this one.

I would equate it to having 3 surfers who are all bitten by sharks. One loses an arm, another a leg and the last loses all but his chest and arms and head. Sure, the last guy is pretty bad off.The guy without an arm simply requires a belt around his arm, he'll be sad but fine. Now you have two doctors able to help shark-bite victiums. Each case would require at least two doctors to work on the patient to ensure success, do you split them up so that both people can get attention?

Lets say both have the same amount of time remaining before treatment, the guy with the lost leg is 80-90% and the guy who lost the most is at 10-20 percent, provided that two doctors work on them. The numbers change when you only use one doctor each.

What do you do? I would think it is clear. Children in Neonatal care have to be thought of as the same. a 30 week old pre-mature baby has a chance of dying too, and they require attention as well.

Anyway, I think life would just be easier if we all devoted ourselfs to using magic eight balls for guidence in our discussions.

-Kirk