Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis?

Abstract

In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing lifeyears. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.

Extremely premature infants, scarcity and the COVID‐19 pandemic

“…Third, we are not aware of a single report from higher income countries of a premature infant denied a ventilator because of COVID‐19 scarcity issues. Some authors have suggested this is happening by confusing shared decision‐making regarding extreme prematurity care with COVID‐19 adult‐medicine triage discussions 6 . In reality, pregnant women choose palliative comfort care for legitimate reasons unrelated to COVID‐19, specifically the overwhelming majority of infants born 22–25 weeks either die in the NICU or suffer moderate‐to‐severe NDI and other chronic health issues (Table 1 references).…”

Liberal Utilitarianism—Yes, But for Whom?

“…For instance, there is an ongoing debate whether guidelines for treating extremely premature babies should be altered to free up ventilators for adults during the COVID-19 pandemic. 33 In some cases, a ventilator would give an adult a higher probability of survival than it would give the extremely premature baby who would otherwise get it. However, saving babies rather than adults would likely maximize life years saved, since a baby who survives is likely to live longer than an adult who does.…”

Using the COVID‐19 as an excuse for unjustified devaluation of preterm infants

“…In their article, Extremely Premature Infants, Scarcity and the COVID‐19 Pandemic, Kaempf et al 1 suggest that the COVID‐19 pandemic has resulted in ‘obstetricians, neonatologists, and/or ethicists (to) blur legitimate extreme prematurity issues of suboptimal health outcomes, resource consumption, and authentic shared decision‐making with care’. We disagree and urge the authors to consider perspectives, highlighted by the pandemic, which help to clarify why many obstetricians, neonatologists and ethicists remain in support of providing extremely premature infants equal consideration in allocation algorithms with other patients 2 . We believe the COVID‐19 pandemic has led to greater recognition of attitudes towards the value of life with disability, 3 thereby challenging the use of health outcome descriptors such as ‘suboptimal’.…”

“…Lastly, claims that processes of shared decision‐making between physicians and parents are in jeopardy at extremes of prematurity is without merit. The authors misrepresent our plea to protect current care options for extremely preterm infants as a threat to the physician‐parent relationship 2 . Thresholds for care options at extremes of prematurity are heavily influenced by professional guidelines.…”