LESSON 6

Low Birthweight Infants

 

Authors:

A revised version of a lesson originally authored by the following Long Island NY science teachers:

Albert Coppola, Robert Frost Middle School, Deer Park

John Marr, West Hollow Middle School, Melville

Mary Kay Marr, Paul J. Gelinas Jr. High School, Setauket

Dennis O'Hara, Miller Place High School, Miller Place

John Piropato, William T. Rogers Middle School, Kings Park
 

Courses for Which the Lesson is Intended:

Intended for middle school and junior high general science classes.
 

Types of Teaching/Learning Activities Employed in this Lesson:

Students are given a handout to read as a homework assignment, which contains factual information about low birthweight infants. In the following class period students are divided into cooperative learning groups. Each group reads and responds to questions about a case study involving the birth of a 14 ounce boy and the problems this presents to various characters in the story. The entire class then discusses the responses of each group. An additional set of questions is presented for an optional follow-up class discussion about the more general ethical problems presented by children who are born with birth defects or special needs.
 

Category that Best Describes this Lesson:

Social issues.
 

Ethics/Values Issues Raised by this Lesson:

Does society have the obligation to provide whatever medical care and other aid is technically feasible to treat a child born with a birth defect or other special needs, regardless of cost?

What are the ethical responsibilities of a family with regard to such a child?

What are the ethical responsibilities of other social agents, such as medical insurers and employers with regard to the birth of such a child?

Should parents be legally libel for actions they have taken, such as drinking, smoking or marital abuse that increased the probability of the birth of a defective child.

Should a handicapped child have the right to sue parents or institutions that failed to take actions to prevent or treat his/her condition?



Lesson Plan
 

1. Students should be given the following fact sheet to study as a homework assignment in preparation for this ethics lesson. To increase the likelihood that students will take this assignment seriously, they can be told that a brief (five minute) written quiz based on the fact sheet will be given at the beginning of the lesson.
Facts About Low Birthweight Infants

a) A low birthweight infant is any baby born weighing less than 2500 grams (5.5 pounds).

b) Low birthweight is the most common cause of serious illness among newborn infants.

c) Even with extraordinary care, low birthweight infants live's are threatened by such problems as frequent brain bleeds, inadequately developed lungs, poor body temperature control and malfunctions of the liver.

d) If they survive, low birthweight infants have a higher than average likelihood of having such serious health problems as birth defects, heart disease, mental deficiencies, poor nervous system development and susceptibility to infections.

e) Smoking, drugs, poor nutrition and stress are all factors that significantly increase a pregnant woman's chances of having a low birthweight infant.

f) Intensive hospital care required by a low birthweight baby typically exceeds $50,000.

g) Care of the smallest babies, requiring the longest hospitalization, can cost as much as $150,000.

h) Low birthweight infants represent about 7% of the babies born in the U.S. each year.

i) Because they are likely to have disabilities children who were low birthweight infants require greater than normal community and school resources for their education.

j) The yearly federal budget for the education of disabled children is about $2 billion.


2. Students should be divided into cooperative learning groups of three of four students. These groups should each be given the case study to read and discuss, and questions to answer (see below).

3. The teacher should lead the entire class in a discussion of the answers recorded by the cooperative learning groups to each of the questions.

4. If time permits, all, or part of the following class period should be devoted to a teacher-led follow-up discussion of the optional questions. The value of this session can be enhanced by asking the students to prepare answers to some, or all of these questions in advance, as a homework assignment.



 

What To Do About Thomas? -- A Case Study


Cast of Characters:

Dr. Robert Fisher

Dr. Fischer, 46, is a pediatrician (children's doctor) and an expert in the care of the newborn at Public University Hospital. He has developed a new medical procedure that has an 80% survival rate for extremely low birthweight (under one pound) babies. Previously, using the normal intensive care given to low birthweight infants, there was almost no chance of survival for such tiny babies. Unfortunately this new method is extremely expensive, costing $450,000 per baby.
 

Joy Smith

Joy Smith, 30, is a clerk in the accounts receivable for the Community Waste Management Corp. She is the mother of one child (Susan, see below) and is and on March 9 she will complete the fifth month of her second pregnancy. This pregnancy, like her first one has been difficult. She would like to work until just before her due date, but back pains are making it increasingly difficult to do her job. She has ignored the advice of her obstetrician to give up smoking and social drinking during her preganancy because of the harm that these habits can cause to her fetus.
 

Michael Smith

Michael Smith, 32, is married to Joy. He is one of the most skilled machinists at Delta-Delta Electronics and earns a base salary of $58,000 per year. Three years ago he and his family moved into an attractive new four-bedroom home. With the new mortgage and a second child on the way, which means that his wife will not be working for at least two years after the baby is born, he has been taking all the overtime work that is available. He hopes that he and Joy will be able to afford the college educations for their children that they didn't have.
 

Susan Smith

Susan, 12, is in her first year at Middleville Middle School. She has made a good adjustment to the new school environment and has developed a large group of friends. She is excited about the prospect of having a brother or sister after years of wishing for a sibling. Susan is already in the school band and the drama club. She also serves one period each day as an assistant in the school library. This year she hopes to try out for the Cheer Leader Squad. At home she has a nice large room with her own TV, VCR and Stereo. She is trying to convince her parents that she also needs her own phone. She has begun thinking about college and would like to attend a good private university like Cornell
 

Dennis Copa

Dennis Copa, 49, is the owner of Delta-Delta Electronics, a small sized, private company with 34 employees. Increased competition in the electronics field has recently reduced the company's profit. Sales of the company's most successful consumer products have leveled off. The company lost a recent bid for a government defense contract. Mr. Copa knows that if he doesn't reduce the amount of expensive overtime work he may have to lay off two or three of his employees. He is also looking into negotiating a reduction in health benefits with the employees union.
 

Joseph Sullivan

Joseph Sullivan, 58, has been the Chief Executive Officer (CEO) of Mega Insurance Corporation for four years. Mega has the contract to provide family health insurance coverage to the workers at Delta -Delta Electonics. Partly due to the increased cost of medical care, Mega's profits have been decreasing for two years. Mr. Sullivan knows that if he doesn't reverse this trend, the stockholders are not likely to retain his services as CEO. He has already down-sized the payroll as much as he can. One option he is looking into is declaring a larger number of new medical procedures to be "experimental" and therefore not eligible for coverage under the terms of the company's insurance policies.
 

The Action:
On February 27th Joy goes into premature labor and gives birth to a baby boy at Public University Hospital. Thomas weighs only 15 ounces. Joy had an easy delivery, is in excellent health, but she and Michael are faced with some very serious and troublesome decisions. They have been told about Dr. Fischer's new procedure for extremely low birthweight babies like Thomas. But they have also been informed that the hospital's policy on low birthweight babies is that "unusual" extreme care, such as that required by the Fischer procedure will only be employed if it is covered by medical insurance, or if the baby's parents agree to full financial responsibility. Otherwise, Thomas will be put in the normal intensive care unit for newborns, which means his chances of survival would be very small. Michael contacts Mega Insurance Corp. and is told that they consider Dr. Fischer's procedure to be experimental, and not covered under his policy. The hospital informs the Smiths that if Thomas is to receive the greatly enhanced survival prospect of the Fischer procedure they will have to agree to pay $300,000 -- the difference between the procedure's $450,000 cost and the maximum amount Mega will pay for intensive care for newborns.
 

Joy and Michael have less than 24 hours to make a most difficult decision. If they can somehow come up with $300,000 they can increase Thomas' chances of surviving for more than a few days, from nearly zero to 80%. They also are told that even if he does survive, the chances of him being a normal, healthy child are less than 50%. He would have an increased risk of having many serious ailments and a 25% chance of dying before the age of 10.

The Smith's total savings amount to $20,000. Fortunately, Joy has a rich uncle who she is sure would agree to help them get a bank loan for the remaining $280,000. But meeting the monthly payments will require a drastic reduction in the family's lifestyle. Joy and Michael decide to involve Susan in the decision. She is told that if they agree to the pay for the Fischer treatment the family will have to sell their new home and move into a much less expensive one in a less attractive neighborhood. Susan will have a smaller room and she will soon have to begin baby-sitting to pay for most of her entertainment expenses. When she is 13 Susan will have to take care of Thomas after school so that her mother can begin to work part time. She will surely have to abandon the idea of having her own phone and also of attending an expensive private college. Michael also knows that before making a decision he will need to confront Mr. Copa and try to persuade him to make an exception and permit Michael to continue to earn at least as much overtime pay as he has in the recent past.
 

Questions:

1. Is it ethical for a hospital to provide a technically feasible treatment only to those who can pay for it?

2. Under the circumstances described, should Mega Insurance be required to pay for The Fischer procedure?

3. Does Dr. Fischer have any moral responsibility to try to make his procedure available to those with limited financial resources?

4. Should everyone have equal medical insurance, or should better policies be available to those who can afford them.

5. Is it fair for the Smiths to ask Susan's to help make a decision that will have negative impacts on her?

6. If you were the Smiths, what decision would you make?

7. If the Fischer treatment could provide a 100% guarantee of Thomas surviving and living a full life as a normal individual, would your answers to any of the preceding questions be different?

8. Should the Smith's take into account when making there decision how they would feel if they agreed to pay for the treatment and then Thomas either died, or became severely handicapped?

9. What moral responsibility should Susan feel for creating this predicament, since her drinking and smoking increased the chances that it would occur?

10. If Thomas survives, but is severely handicapped, should he have the right to either sue his mother for child abuse, or to sue the hospital or his parents for treating him, rather than letting him die?

Questions For Optional Follow-up Discussion:

1. Using intensive care procedures on children who would otherwise die results in larger numbers of retarded and handicapped children. What is your response to this ethical problem?

2. Should decisions about whether to use expensive medical techniques be based on some form of comparison of costs and benefits?

3. According to a U.S. Child Abuse law that went into effect in 1984, all infants with disabilities are to receive nutrition and other medically indicated treatment with three exceptions:

a) the infant is in an irreversible coma,

b) the treatment would only prolong dying and would not be effective in treating the infant's life-threatening condition.

c) the treatment would be futile in terms of survival and under such circumstances would be inhumane.

Do you agree with this law? Do you think that it would require a hospital to use an expensive "experimental" method like the Fischer procedure in the case study on all very low birthweight infants?

4. Some obstetricians will not make a great effort to resuscitate a severely handicapped newborn infant that experiences heart arrest. Do you think this is ethical?

5. Would it ever be ethical to withdraw treatment from an infant with a poor chance of survival in order to provide intensive care for an infant whose chances of surviving are greater?

6. Some medical policy makers have proposed that the public funds that are now made available to provide intensive care to infants with poor survival chances should be reduced in order to provide more funds for prenatal care for women who are at risk of giving birth to a low birthweight infant. What do you think about this proposal?

7. Wrongful life lawsuits brought against hospitals, doctors and even parents involve a claim that a severely handicapped child's life is worse than death or nonexistence. What is your opinion about such lawsuits?

8. Wrongful birth lawsuits involve claims against hospitals or doctors by parents that a severely handicapped child was born because of negligence on the part of the medical personnel in denying them the opportunity for an abortion. What is your opinion about such lawsuits?

Discussion:

Teachers report that the student complaint "That isn't fair" is becoming increasingly common. Frequently what the student means is that some personal expectation or desire is not being met. This lesson provides an excellent opportunity to get students to confront the difficulty of meeting individual needs within the constraints imposed by a society with limited resources.

As the students should learn from this lesson, the task of developing necessary policies for prioritizing the allocation of human, material or financial resources in an ethically fair manner is extremely difficult. The rub is that there are strongly held, sharp differences of opinion about what constitutes a fair policy. For example, wealthy people will generally favor a system that allows limited resources to be purchased by anyone who can afford them, whereas poor people will demand a system that distributes these resources in a manner that provides equal access to people in all economic strata.

These are issues that will become increasingly important as rapid advances in biomedical technology continues to make it feasible to devise healthcare options that can not possibly be made available to everyone. Government officials in the Oregon have already learned how divisive it can be to attempt to define a scheme for rationing healthcare. Questions like whether a kidney transplant should go first to the patient who needs it most desperately, or to the one whose life is likely to be prolonged the most, can not be answered in ways that will be agreed to by everyone. All of today's students will be choosing governmental officials who will be faced with the task of achieving a political consensus on these vital, value-laden questions.


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