Million dollar babies - when do we stop trying to save preemies?

Neonatal intensive care units (NICUs) are very profitable endeavors for hospitals. They require lots of fancy equipment and very skilled caregivers. They are able to save babies earlier and earlier, and keep them in better health. They also cost a lot.

Our baptismal covenant asks us to respect the dignity of every human being. Indeed, improving medical technology that allows us to save premature children born earlier and earlier must surely improve human dignity, all else being equal.

Billie Lou Short, NICU director at Children's National, says the typical 28-week-old preemie had a 20% rate of survival in the 1980s. Now those infants "have a 90% survival rate and considerably reduced side effects." The percentage of such children with permanent disabilities has dropped to about 15% from as high as 40%, she says. Ciaran S. Phibbs, an associate professor at Stanford University's Health Research & Policy Dept., adds, "NICUs have had a dramatic positive effect."

However, all else is not equal. Treatment for premature babies costs a lot.

In the U.S., corporations handle most of the financial burden. Employers generally cover some or all of the hospital charges in their health plans, and they also must deal with lost work hours of staff who spend weeks, sometimes months, attending to their premature infants. Corporations pay out nearly 15 times as much for babies born prematurely in their first year of life as for full-term babies, at an average cost of about $41,000 per child. For the earliest of the preemies, who are born in fewer than 28 weeks and spend up to three months in the hospital, the tab is higher. Says Waitzman: "The million-dollar babies are there."

Additionally, babies that survive still have higher odds of lifetime disabilities, which is also expensive.

That said, some health economists argue that overall, investing in preterm births is a good investment.

The cost calculations are just as controversial, but most health-care economists seem to agree that spending on preemies offers a high rate of return for all but the earliest-stage infants. The reason? The money improves both the quality and length of life, which yields big economic benefits. Between 1960 and 2000, the U.S. infant mortality rate—the rate at which babies less than 1 year of age die—dropped 73%. It fell from 26.0 to 6.9 deaths per 1,000 live births, according to the Centers for Disease Control & Prevention. The staff at Children's National consider this a huge triumph. Billie Lou Short, NICU director at Children's National, says the typical 28-week-old preemie had a 20% rate of survival in the 1980s. Now those infants "have a 90% survival rate and considerably reduced side effects." The percentage of such children with permanent disabilities has dropped to about 15% from as high as 40%, she says. Ciaran S. Phibbs, an associate professor at Stanford University's Health Research & Policy Dept., adds, "NICUs have had a dramatic positive effect."

The money society invests in low-birthweight infants who survive produces a high rate of return, according to Harvard professors David M. Cutler and Ellen Meara. They argue it is much more cost-effective than, say, coronary bypass surgery. Admittedly, it is hard to calculate the value of a life in terms of financial returns. Regardless, "the benefits [of preemie care] are substantially greater than the rise in costs," insists Meara, assistant professor of health-care policy at Harvard Medical School. She also notes that innovations in preemie care, such as ventilator technologies and surgical procedures, can be applied to full-term infants, greatly amplifying their social impact.

That said, the authors quoted above don't seem to give a limit. A British bioethics council proposed a 22 week limit. One pro-life group argued for 20 weeks, but experts in preterm birth seem mostly opposed. There's a point of diminishing returns with everything, and it would seem that that point is around 22 weeks for preterm infants.

Asking broader society to bear a disproportionate financial burden to save a few lives may not be compatible with increased human dignity. For sure, there is some point along the scale when society will cease being able to bear the costs. That sounds bald, but there it is.

Steven Pinker, a well-known linguist, argues here that "human dignity" is a very poorly-defined term. He has a point. Specifically, he argues that the Roman Catholic Church throws it out whenever anyone does something they don't like. He has a point there, too, although I think some of his criticisms miss the mark.

However, I think that the concept of dignity is valid, we just need to do a better job defining it.