British Section of the World Federation of Doctors Who Respect Human Life

Daily Telegraph (London)

16 November 2006

As ethics experts recommend that babies born at 22 weeks should not be resuscitated, Professor Stuart Campbell voices medical opposition

As an obstetrician for more than 40 years, and a specialist in diagnostic scanning and foetal medicine, I have seen life at all its stages: from those first fuzzy images on a 12-week ultrasound scan through to the poignant 4-D images (which my team pioneered) that show foetuses sucking their thumbs or ''walking'' in the womb. I have witnessed the miracle of a full-term birth many times - but also the despair for the parents of a baby that arrives at 17, 18, 19 weeks' gestation. I have watched those tiny chests grimly simulating respiration, the baby's face contorting into a silent cry but its immature lungs unable to take in oxygen and make life possible. The moment of birth can be wonderful and terrible to behold.

Take a baby born spontaneously at 21 or 22 weeks. Its body may be twitching and moving but there is no sustained breathing. Its skin is grey, not pink, and its heart rate is slow. No paediatrician is going to strive to keep this child alive, to incubate it or force oxygen into it. There is no point.

Yet from 22 weeks on, viability is becoming an issue, a sometimes difficult one. After all, by 23 weeks - a mere seven days later - up to 60 per cent of babies can survive, according to a 2004 American report from the Children's Hospitals and Clinics of Minneapolis.

Of course, there are many who will welcome the Nuffield report. Currently, there is a natural timetable around the 22-week mark that delineates between life outside the womb and death. Formally recognising this as the cut-off point, if artificially and arbitrarily, removes the moral and practical weight of difficult decisions from the doctors and parents, and the report's conclusion appeals to those who believe that difficult decisions must be made for the greater good.

Those concerned with the rationing of limited NHS funds will also be encouraged. And, of course, it will find support in a modern world that is not particularly accepting of disability; very premature babies will often grow up with some degree of handicap.

Yet what do we really gain by deciding that 22 weeks is the life or death moment for a baby? Let's look at the arguments in reverse order. Parents of premature babies fall into two camps - those who are worried that if the baby survives it will be severely disabled in some way, and those for whom this baby is so important that disability ceases to be the main issue. The first camp prefer to allow their newborn to slip away peacefully, and then to grieve. The second will move heaven and earth if they can to keep their child alive. This group often includes women who have faced infertility, or have had multiple miscarriages, or those who have had to resort to IVF that often results in premature arrival.

Neither group of parents is wrong. A change in practice will not affect how either feels - the former would have already reached their decision; the latter will still be desperate to ensure that their child is saved. All we gain with a timetable is the loss of humanity.

Furthermore, establishing a baby's gestational age is not an exact science. Most doctors are often one or two weeks out in their estimation. Before Nuffield's recommendation, a mistake might lose you a horoscope sign; after Nuffield it could be much more costly.

For those concerned about the NHS balance sheet, it is worth pointing out just how few babies we are talking about - perhaps 200 are born spontaneously every year at around 22 weeks. Of those, approximately 20 will have a realistic chance of living but only a small percentage will make it. Some feel we should be concentrating our energies on premature babies born at 24 or 25 weeks whose chances of survival are much greater. But this is not an either/or situation - saving a baby born at 22 weeks and four days does not mean fewer resources for one born a few weeks later. In a system where the waste of money is mind-boggling, saving a score of premature babies each year will not have a huge impact.

It's worth making a point about medical progress. When the 1967 Abortion Act came into force, 28 weeks was considered the lowest level a child could survive at, and thus set as the upper limit for termination. Now, there have been such strides in neo-natal care that babies born at 26 weeks not only survive but are often free of long-term health problems. I believe that the new upper limit should be set at 20 weeks because who knows what advances we will see for babies born at 22 weeks over the next five years?

In conclusion, I have to ask whether or not - with Nature so firmly in control anyway - this report was actually necessary. It won't alter paediatricians' behaviour; as I've pointed out, they will not try to force a baby to live when there is obviously no hope. Conversely, no law in the land will stop a doctor trying to save a premature baby whom he or she believes has a genuine chance of life. Do we really want the Nuffield report to take precedence over the Hippocratic oath? Should a doctor turn his back on a baby who is fighting hard to live?

This report promises to take away painful responsibilities from parents and doctors but at the same time it is also denying them the opportunity to discuss each case on its merits. Worse, I believe it promotes a culture of ''throwaway babies'' - those deemed not good enough or worthy of life are tossed to one side.

I sincerely hope that the Royal College of Obstetricians and Gynaecologists and the British Paediatric Association decline to endorse it. It would be foolish not to do so and the only thing that would change would be the way we doctors are perceived by the public. We would be seen as unfeeling and uncaring.

There will always be some paediatricians who question the rights and wrongs of trying to keep very young babies alive. But, to put it bluntly, it is part of their job. They have to keep on trying; we all do - for that, after all, is life.

Prof Stuart Campbell is a consultant at the Create Health Clinic, London, and formerly head of Obstetrics and Gynaecology at King's College School of Medicine