Book Review

John D. Lantos, MD & William L. Meadow, MD, PhD, Neonatal Bioethics:  The Moral Challenges of Medical Innovation, The Johns Hopkins University Press, 2008. 192 pp. paper, $27.00.

In Neonatal Bioethics

The Moral Challenges of Medical Innovation, John Lantos and William Meadow attempt to shed light on the ways in which medical innovations are incorporated into current medical practice by using the field of neonatology as an example. They provide an engaging discussion of the complex forces-medical, ethical, legal, & political-surrounding the development of this unique field, and review the history of neonatology through several eras. 

The chapter on the “Era of Innovation” describes the way in which new medical technologies were incorporated into practice in the early years of neonatology and the accompanying pitfalls of this “messier and more fertile” process of innovation, which dominated the beginning of neonatology.  Descriptions are offered of the moral issues which arose following this rapid period of innovation and the authors highlight the early attempts by leaders in the field to analyze the ethical issues associated with the new clinical interventions which had been incorporated into practice.  The chapter concludes with descriptions of the legal cases from this era and exposes the “mysterious disjunction between medical practice and legal theory” which existed at the time.

In the “Era of Exposed Ignorance” the authors compare the less formal methods of innovation which dominated the early era with the more formal, classic randomized trials which were utilized in the development of pulmonary surfactant, “one of the great success stories of medical science.” The social, political and legal ramifications of the Baby Doe case are described with an illuminating discussion on the global concept of “quality of life,” including the differences in the perceptions by doctors and parents in this concept as it pertains to sick infants.

The book concludes with discussions of “The End of Medical Progress” when “progress in improving birthweight-specific survival rates came to a halt,” the economics of the NICU and further analysis of the moral choices which have been discarded and moral progress which has occurred in the field of neonatology in which we have “come to a new understanding of ourselves and our moral obligations that is quite different from the understanding of those moral obligations that we started with decades ago.” 

As a young neonatologist, I feel a duty to reflect on the many ethical issues which surround the practice I have chosen, and to learn from what has transpired in the field of neonatology in the past. That said, it is dissatisfying at times to read books or articles on neonatal medical ethics, because too often these texts seem too inconclusive, cerebral and out of touch with the sometimes messy and emotionally-charged day-to-day practice of saving babies.  One of the most valuable contributions of this book lies in its continual acknowledgement that the process of decision-making in the NICU is agonizing, and is occurring on an individual basis under stressful conditions with uncertain information.  The authors also acknowledge that the societal process of arriving at a moral consensus on which to base these decisions is “iterative, nonlinear and ongoing.”  Instead of feeling dissatisfied with this conclusion, the authors are able to provide the reader with a sense that this is the way to moral progress.  Decisions we make today regarding the care of sick infants, may not be the decisions we will make in the future, but that is the nature of progress. “We take a tentative collective choice to accept a certain morality.  We observe the effects.  We move forward.  We change.”  This book should be required reading for neonatologists-in-training, and recommended reading for anyone interested in neonatology and the ethics of medical innovation.