Book Review

Neonatal Bioethics: The Moral Challenges of Medical Innovation

N Engl J Med 2007; 356:97-98January 4, 2007

Article

Neonatal Bioethics: The Moral Challenges of Medical Innovation
By John D. Lantos and William L. Meadow. 177 pp. Baltimore, Johns Hopkins University Press, 2006. $35. ISBN: 978-0-8018-8344-6

Shall the littlest of children lead? Neonatology is a relatively young field, but its history is unquestionably remarkable in many dimensions. In the past 50 years, both neonatology and the care of the sickest and smallest babies have evolved dramatically. John Lantos and William Meadow take us through the rapid advances in care, as well as the enabling changes in law, economics, and moral values. The authors also address the accompanying ethical conundrums, in both research and clinical care. In the end, with neonatology as a case study, they take us well beyond the confines of this new field to examine broader issues in medical innovation.

The book first introduces the reader to the context of neonatology, with its early dramatic reductions in mortality rates attended by troubling moral concerns. The authors then propose three eras in the history of neonatology — the first marked by individualism and rapid innovation, the second beginning with the case of Baby Doe (in which the parents of an infant with Down's syndrome refused to consent to surgery for esophageal atresia), and the third characterized in the chapter title “The End of Medical Progress.” In parallel, they document an early decentralized and unstructured period of rapid medical innovation maturing to a more modern understanding of translational research. Is this coevolution coincidental or inevitable? How should we strike a balance between progress and protection? The subtitle of the book, “The Moral Challenges of Medical Innovation,” poses a central theme.

The authors enliven the discussion with many dramatic contrasts: Should the neonatal intensive care unit be seen as a savior or as a system run amok? Should neonatal care be seen as an investigational tool or as a right, as was argued by some observers in the case of Baby Doe? The authors develop a vision of innovation in neonatology as iterative, nonlinear, and sometimes troubling, but in the end, undeniably successful. They contrast this approach with that of more traditional linear investigation, with its identifiable seminal discovery and neatly framed hypothesis. In the final chapter, they develop important insights about the current framework for medical innovation and care in neonatology.

Lantos and Meadow support their account with a review of the professional and lay literature. An acknowledged weakness of the book is that secondary sources may not depict actual practices with accuracy. A good example is the case of Baby Doe, which was unique, highly polarizing, and the source of a broad range of opinions in the lay and professional literature. Lantos and Meadows are pediatricians, not social historians, and they guide the reader through potentially treacherous topics using their experience as both clinicians and students of ethics. The result is a conversation with the reader that is fluid, collegial, and easily read. The authors provide more questions than answers.

Some readers may find the book idiosyncratic and personal, uneven rather than encyclopedic in its historical presentation, referenced with an unusual blend of experience, lay citations, and scientific citations, and selective in its chosen topics and conclusions. The selectivity is clearly intentional, and it is used skillfully to frame both discussion and argument. In the final analysis, one need not agree with each point to appreciate the value of the dialogue.

This book is insightful and thought provoking. I highly recommend it to anyone interested in the health of children but particularly to those currently in training, since it contains important history and an introduction to the key issues in the field. But I believe the book's potential readership extends to all students of innovation. With neonatology as a paradigm for innovation, our littlest children lead us to questions for all of medicine.

John W. Sparks, M.D.
University of Texas–Houston Medical School, Houston, TX 77005
john.w.sparks@uth.tmc.edu