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There are not too many bioethical books that successfully unite philosophical competence in ethical judgment with seasoned medical expertise. This work on the theory and practice of medical care for prematurely born children (neonatology) is one of them. In a fascinating account of the advances in neonatology over the last thirty years, John D. Lantos and William L. Meadow portray the history of this rapidly evolving subfield of medicine. Their description also lends itself to a broader bioethical audience by addressing recent bioethical and medical innovations in general.
According to Lantos and Meadows, the major steps in the history of neonatology were the following: After the flash flood of novel technologies during the 1960s and 1970s (p. 19ff.), neonatology passed through many turbulent waters in the 1980s up into the mid-1990s (p. 53ff), before it finally joined the calm sea of conventional academic wisdom (p. 85ff.). Each period had its distinct moral issues and problems. In the era of tempestuous innovation, abstract questions regarding the very purpose of neonatal care as well as about the fundamental legal rights of children and parents (e.g., liability for "wrongful birth") dominated the inquiry (p. 36ff.). An "Era of Exposed Ignorance" succeeded; it centered on the "Baby Doe" case (p. 66ff.), which revealed that the public perceptions of neonatal care (i.e. doctors overimposing care) and empirical reality (i.e. undertreatment of neonates) were wildly diverging. As a response, and in an endeavor to make the different neonatal practices and technologies both known and comparable, standardized databases were established (p. 83).
Why did these corresponding changes occur just in that way? Lantos and Meadows explain that in the beginning practitioners and theoreticians were overwhelmed by technological progress, its speed and innovatory power. Ordinarily in medicine an accepted paradigm of knowledge provides intellectual orientation, but in the early days of neonatology this was not the case. Due to the lack of agreed-upon frames of reference, scientists could not operate with ceteris paribus assumptions, and had to shift from theories of direct causation to theories of systemic causation (p. 2). Such a paradigm shift, however, impinges on our capacity for ethical judgment. Moral responsibility is assigned with comparative ease where, except for one controlled change, all other things remain equal. However, when everything is in flux and operative knowledge is debated, ethical judgments concerning the merits and demerits of novel technologies become extremely difficult and uncertain. This explains the highly conflicting moral judgments of the first phase of neonatology.
The second phase was characterized by the both blissful and baneful accidents that in a time of rapid and dramatic technological change are bound to happen. These accidents in turn contributed to the very development that occasioned them, carving out the ways that medical theory and practice later decided to follow, or avoid (p. 137ff.). Over time, scientific discovery always tends to establish patterns; it gradually slows down to a speed that allows for more oversight, planning, and ethical circumspection. The same happened in the second phase of neonatology. Founding ethical judgments upon concrete empirical data rather than abstract categories, this phase brought about conceptual moderation and a period of more case-sensitive decision-making.
With "consensus about facts" (p. 108), say the authors, dissent about the underlying values became clearer. The empirical approach consolidated not only the pertinent knowledge (which raised the level of prognostic accuracy), but also revealed something else: a decelaration of progress in the field (p. 86). While the blessings of innovation at the cost of unavoidable mistakes, the benefits of controlled progress were paid for with slower development. Ethics committees became involved (p. 119).
The legal question -- when to give or to withhold care -- connects individual cases to the broader societal discourse about health care in general (p. 123ff.) and hospital finance in particular (p. 129ff.). Naturally, the reimbursement policies of insurance providers and public health care systems affect the quantity and quality of care hospitals are going to offer. So, how should society set the respective legal parameters and economic incentives? Lantos and Meadows give a largely procedural answer. In a balanced retrospective (p. 150ff.), they explicate the morale of their analysis of the history of neonatology for biomedical ethics overall, and plead, notwithstanding the eternal conflict over the right ethical criteria, for an eminent role of bioethics in medical decision-making.
"Because scientific discoveries carry within them the seeds to both triumph and tragedy, we need to be attentive and cautious to the possibilities that our deepest hopes might lead us to create our worst nightmares" (p. 157). We should not let economic imperatives of hospital management and insurance providers drive bioethical decisions. Instead we, as a society, ought to set the relevant criteria first and then transform the legal and economic framework for the health care system accordingly. Surely, the "process of moral consensus is iterative, nonlinear, and ongoing" (p. 155), yet that is not actually an argument against the social oversight over the biomedical research enterprise. We need room for a constant revision of past decisions. So, even if ethics committees sometimes retard innovation processes, they are a crucial part of the process. The real question is less concerned with who is more likely to be right: the scientist or the committee, but rather who has the right to error; hence, the need to democratize the bioethical debate. Medicine and health are "too important a societal matter to be left to either physicians or medical administrators" (p. 154).
N.B. I am very grateful to my assistant, Tracy Flynn, for smoothing out my Teutonic English.
© 2007 Claus Dierksmeier
Claus Dierksmeier is Professor for Philosophy at Stonehill College in Easton (Boston), MA. His specialty is the practical philosophy of the 18th --21st century.
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