Book Review

The Lazarus Case: Life-and-Death Issues in Neonatal Intensive Care

N Engl J Med 2002; 347:375August 1, 2002

Article

The Lazarus Case: Life-and-Death Issues in Neonatal Intensive Care
By John D. Lantos. 183 pp. Baltimore, Johns Hopkins University Press, 2001. $22.50. ISBN: 0-8018-6762-2

Neonatal intensive care is one of the most dramatic recent advances in medicine. Every year, 53,000 babies are born prematurely in the United States. The newborn intensive care unit, with its sophisticated technology, has become the artificial womb for these infants, and although most infants treated in this unit go on to lead full and productive lives, others are left with multiple problems, such as blindness, seizures, chronic lung disease, and neurologic damage. This is one reason the health care system in the United States is sometimes seen as mindlessly driven by a technological imperative.

In The Lazarus Case, John Lantos, a pediatrician and ethicist at the University of Chicago, critically examines the moral predicaments physicians face in making choices for these vulnerable infants. As an illustration, Lantos presents a malpractice case, one that is really an amalgam of cases in which he has testified as an expert in medical ethics. The case is that of a premature infant who is born at 25 weeks' gestation and weighs 650 g and for whom cardiopulmonary resuscitation is performed at birth. After 10 minutes of resuscitative efforts, the neonatologist decides to stop. Unexpectedly, however, the infant survives but has severe neurologic damage. The neonatologist is sued for having provided inadequate resuscitative efforts. Lantos highlights the moral choices faced by the parents and the health care team. In describing their agony over the morality of suffering that is associated with neonatal intensive care and the uncertainty of outcomes there, the author very nicely draws on the work of distinguished authors such as Feodor Dostoyevsky, Kenzaburo Oe, Lewis Thomas, and Mark Twain. He says, “Doctors who pursue survival at any cost can be seen as morally pure or morally simplistic or profoundly irresponsible and insensitive to the needs of real human communities.” As Lantos “wrestles” with the plaintiff's attorney, he brings out the disparity between moral theory and professional practice.

Lantos has taken an important practical problem and applied our understanding of moral and ethical theory to the issue of the appropriateness of care. An important message here is that in the context of this particular case, there are no right or wrong answers to the questions posed. This book will be of interest to the general public and to health care workers. At times, technical details are injected into the narrative that would be difficult for nonmedical readers to understand. The style of writing would have benefited from editorial assistance. However, these are minor reservations about a book that has admirably succeeded in its purpose — to convey the essence of moral dilemmas faced each day by those who care for these vulnerable, extremely premature infants.

I. David Todres, M.D.
Massachusetts General Hospital, Boston, MA 02114
itodres@partners.org