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End Of Life Decisions At The Beginning Of Life

In the next decade, our nation will be defined by how we grapple with escalating health care costs.

Today, health care comprises 18 percent of GDP in the U.S. If the current trajectory continues, health care costs are on a course to consume roughly half of the nation’s GDP by 2082, according to the Congressional Budget Office. While politicians appear paralyzed out of fear of losing elections and act as if procrastination can substitute for seriously constructed policy, our nation slips further into a moral and financial crisis.

Each of my columns in the past year has focused on a topic related to the choices needed to mitigate our cost trajectory. The heartrending decisions regarding the treatment of preterm babies in neonatal intensive care units (NICUs) are more in the basket of demands. According to the American Hospital Association, the number of births between 1997 and 2012 rose less than 2 percent, but NICUs expanded by about 60 percent. It is now “fairly common” to resuscitate babies born at 22 weeks, says Dr. Craig Jackson, Medical Director of Neonatology at Seattle Children’s Hospital. Hospitals have become adept at saving preemies; babies born at 27 weeks now survive about 90 percent of the time. However, about two thirds of babies born prior to 27 weeks have some kind of disability by age 3 and require chronic medical care.

Here is the dilemma. Hospitals– especially children’s hospitals– are buoyed financially by profits generated in NICUs. In many hospitals, the NICU is the largest profit center. “Within the hospital world, whenever there’s a tradeoff that’s necessary, the tradeoff is made in favor of the kinds of services that are more profitable because that’s how we have organized our health care system,” says Dr. John Lantos, a pediatrician and bioethicist at Children’s Mercy Hospital in Kansas City.

Prematurity is both a financial burden for society and a profit source for hospitals. According to the March of Dimes, babies born before 32 weeks have an average hospital bill of $280,000, about 56 times as much as a healthy, full-term baby. Much of that money goes toward NICU care. Prematurity costs employers more than $12 billion yearly in excess health costs. Add to that the cost to the taxpayer for NICUs and chronic disabilities.

In 2014, AOL CEO Tim Armstrong made headlines when he announced that the company would need to reduce employee benefits due to two “distressed babies” that cost AOL about $1 million each. After a huge outcry, the company restored benefits. AOL is a microcosm of what unsustainable demand looks like.

Just because we can save extremely low birth weight babies, does it mean we should?

Should we not be looking to establish a decent minimum of health care– at the very least for the 29 million who remain uninsured– versus dedicating scarce dollars to a select few? I am not arguing that an imperiled newborn is less than a full person or lacks the right to be considered on the same level as any other patient. However, I do argue that we have a duty to use resources in proportion to the common good of all.

As Charles C. Camosy concludes in his book, Too Expensive to Treat? Finitude, Tragedy, and the Neonatal ICU, “regardless of whether one is old or young, rich or poor, disabled or not, part of a racial minority or majority, everyone has equal dignity and an equal right to use a proportionate amount of community resources. Unfortunately, in light of our tragic and finite human condition, this means some will not get care from which they would certainly benefit.”

These are difficult choices. According to Camosy, 65 percent of neonatal physicians and 75 percent of neonatal nurses “gave economic costs of intensive and lifelong care as a reason” for thinking that not all infants in NICU should be saved. Should we not use that as a platform for greater policy discussion? Or is it the third rail, again?

Our current de facto triage system of rationing is driven by the politically powerful and by public sympathy, not by sound public policy that provides justice for all.

The health care industry has become intensely focused on delivering acute-care in a crisis or an emergency, rather than preventive care to head off problems before they start. Rather than directing resources toward prevention and taking care of chronic conditions such as high blood pressure, diabetes, obesity and poor nutrition– all of which contribute to the incidence of preterm babies- we spend dollars on the disruptive technology that generates disproportionate profits and captures headlines.

“One in four adults [who were fully insured for all of 2014 under the Affordable Care Act] still reported that they went without some needed medical care because they couldn’t afford it” according to Lydia Mitts, a senior policy analyst with the health care advocacy group, Families USA. Are we abandoning this population as a result of our disproportionate use of scarce funds?

Our current de facto triage system of rationing is driven by the politically powerful and by public sympathy, not by sound public policy that provides justice for all. No one wants to face discussions of foregoing treatment at any stage in life. Social justice demands painful end of life decisions at both ends of life in order to serve the common good. As Protestant theologian Paul Ramsey once said, “the function of medicine is not to relieve the human condition of the human condition.”

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