Progress in Intensive Neonatal Care Prompts Ethical Concerns

Times Staff Writer

Rapid technological advances in treatment of very ill or low birthweight babies are, at long last, being overtaken by related ethical concerns about how much should be done for a profoundly debilitated newborn and fears about the psychological toll of weeks or months in a neonatal intensive care unit.

That is the assessment of a USC neonatologist reviewing the state of medical care for newborns in an annual special issue of the Journal of the American Medical Assn. that is devoted to giving the previous year’s medical progress a rational perspective. The newborn essay, by Dr. Joan Hodgman, appeared in the journal last week. Among her major points were these:

- Until recently, the advent of high-tech treatments--unquestionably responsible for improving survival rates among critically ill newborns--has proceeded with scarcely any attention being paid to its psychological or behavioral effects. Now, however, specialists are starting to concern themselves with the latent and immediate mental health toll when a very young baby must spend weeks or months wired to monitors in an incubator in a special nursery.


- The ability to improve survival rates for very low birthweight babies--those weighing less than a pound--has raised major ethical questions about whether treatments that may prolong life at enormous cost or risk of mental retardation or lifelong physical disability ought to be attempted even if they are technologically feasible.

“Biomedical ethics has entered the high-risk nursery,” Hodgman wrote in the journal. “Newborn and, particularly, premature infants are not inert and passive organisms, but beings capable of interacting with their environment. Methods to reduce stress for the infant (in the neonatal ICU) are being studied, with encouraging results.

“We have reached a stage in neonatal technology where we are recognizing that all that could be done is not necessarily what should be done.”

Cataracts and Costs

Although cataract surgery has moved almost entirely out of inpatient operating rooms and into doctor’s offices and outpatient clinics since 1983, the procedure is still characterized by pronounced regional cost differences--a factor bound to pressure a health system that will provide about 2 million operations a year by 1989.

And such differences in cost from state to state and region to region will assume greater importance as government and private insurers struggle to provide for the health care needs of an increasingly gray population.

As the Baby Boom generation ages, more cataract surgeries will probably be necessary and the need to control expenditures on eye surgery will become critical. A new analysis of regional variation in cataract surgery costs has just been published by the Metropolitan Life Insurance Co.


The tally shows that cataract surgery--which today can be done on an outpatient in less than an hour and generally involves replacing fogged sections of the eye’s natural membrane with a plastic replacement lens--costs an average of $5,410 nationwide. The vast majority of cataract surgeries are paid for by the federally funded Medicare program--since patients who have the surgery are most often 70 or older--or by private insurance. Medicare has taken some steps to impose uniform fees, but the actions apparently have not been sufficient to eliminate inexplicably large regional price variations.

Because of differences in physician fee patterns, outpatient operating room fees and other variables, the identical operation costs private insurance plans $7,290 in Arizona, $7,110 in Pennsylvania and $6,740 in California--but only $4,580 in Missouri, $3,750 in Tennessee and $3,340 in Vermont. Concluded Metropolitan Life: “Increased surveillance of the charges associated with this procedure in (both hospitals and outpatient clinics) is obviously in order.”

Asthma and Workplace

Occupational causes of asthma attacks may be more common than experts have previously believed and nonsmokers--though their risk of being asthmatic is not much different from smokers in the population at large--have a significantly greater chance of the disorder being triggered by workplace factors.

Of more than 6,000 research subjects involved in a new UC San Francisco analysis, nearly 8% identified themselves as asthmatic and more than 15% of those who suffer from the disorder attributed it to occupational factors. The percentage of suspected workplace-related asthma was significantly greater than what has been reported in previous studies.

The new research--reported in the journal Chest--found industrial and agricultural workers to be at greater risk than people employed in white collar or service jobs. The largest occupational asthma risk was for workers employed in farm machinery manufacture. Other high-risk fields were coal mining, general agriculture, textile manufacture, bakeries and the wood products industry.

Workers who had never smoked had an occupational asthma risk nearly four times greater than smokers--a variation that could not immediately be explained. “These data indicate the problem of occupationally related asthma may be larger indeed than previously estimated,” the UC researchers concluded.


Hot Tub Legionnaire’s

Though Legionnaire’s Disease--an unusually aggressive and proportionately fatal strain of pneumonia--is rare, clusterlike outbreaks continue to confound public health officials. And while the public at large may first glance nervously at air-conditioning ducts whenever Legionnaire’s is mentioned, the disease organism is proving resourceful in its search for ways to spread.

Now, in a new wrinkle in the disease, a group of cases has been linked to a whirlpool spa at a Vermont inn.

Reporting in the journal Annals of Internal Medicine, Vermont health officials and an expert from the Centers for Disease Control in Atlanta described three cases of Legionnaire’s among guests of the inn.

Determining precisely what the patients had in common turned into an exercise in medical detective skills since all of them had stayed at the inn but had used different facilities in the four to 10 days prior to coming down with Legionnaire’s. Finally, officials settled on the spa as the source of the organisms--ruling out the swimming pool, even though the pool was in the same room as the hot tub.