The tyranny of a kilogram : should we untie rather than cut the Gordian knot?

[摘要] ENGLISH ABSTRACT: The number of babies requiring neonatal intensive care exceeds the facilities available. Theassignment questions the perceived shortage of resources and investigates methods of resourceallocation.The first chapter addresses the development of technology and reflects briefly on the romancebetween medicine and technology. The second chapter addresses the issue of prognosis of thesmall preterm neonate and reflects on how these data are derived and the assumptions that areoften made based on prognostic data. Chapter three concentrates on how outcomes discussedin the second chapter may be quantified. Individual utility quantification plays a role in decisionmaking for the individual neonate, while comparative utility quantification addresses some of theissues concerned with the macroallocation of resources.This leads into chapter four that addresses macroallocation and challenges some of theassumptions that resource allocation is based upon. Are resources scarce? Are there financialconstraints? What is the role of medicine in health? Will redistribution of wealth necessarilyimprove the health of the population?Who should. make decisions for individual sick neonates regarding neonatal intensive care isaddressed in the next chapter. The tension between sanctity-of-life and quality-of-life ideologies,created by life sustaining technology has been legally and ethically settled in favour of thepatient's right to self-determination, based on the principle of respect for patient autonomy. It willhowever be argued that the traditional four principles cannot be utilised as the neonate is at bestpre-autonomous. Moral obligations towards the neonate are dependent on the beneficence andnon-maleficence obligations of the parents and the caregivers. Both these principles are primafacie and may have to be tempered by distributive justice.Plato's absolutist thinking and Descartes mathematician's perspective, have influenced medicine'sromance with certainty. If knowledge and certainty are necessary for decision· making and it isshown that absolute certainty is elusive, should we be nihilistic about decision making in neonatalintensive care? Chapter 6 critically assesses three approaches to decision making in thepresence of prognostic uncertainty. In contemporary medicine there is a constant tension between the traditional commitment to thepatient on the one hand and the awareness that resources are finite on the other, this tension is anunfortunate reality of medicine. To constrain the growth of medical expenditure, doctors are nowasked to serve simultaneously as society's agent of cost containment and as the patient's agentfor maximum health. There is increasing pressure on doctors to serve two masters, society andthe patient. Acting on behalf of society as a gatekeeper, while for the patient the doctor isexpected to act as advocate. Chapter seven investigates both gate-keeping and advocacy andattempts to answer the question whether doctors can and indeed should try to serve two mastersSimultaneously?The final chapter brings together the threads of the various extended arguments and attempts togive solutions to some of the conundrums.

[发布机构] Stellenbosch University