The baby was very tiny and premature. After eight days of life, not only were her lungs in bad shape, but her liver and kidneys were failing too. My partners and I discussed whether ongoing treatment would be futile, whether perhaps we were prolonging suffering, whether we should offer to take the baby off the ventilator and allow her to die.
The mother of the baby was an illicit drug user who I suspect was homeless, and who certainly had little or no social support. She rarely, if ever, visited the hospital. As we discussed what to do with the baby, one of my partners, to my surprise, said that he thought one of the factors in our decision-making ought to be the baby’s social status. The baby was, he said, effectively unwanted. By his logic, that fact made it easier to let the baby die — easier, at least, than if the baby had loving parents who wanted her and could care for her.
I was floored by my colleague’s remark, but also a bit puzzled. It was an out-of-character comment; my partner had always been a fine and empathetic neonatologist. I believed that all babies had inherent self-worth, regardless of the parents’ social standing. If we let social standing influence these decisions, I knew the potential for discrimination was great. It was a slippery slope: What would stop factors like race or gender from influencing a decision, even if all of us believed we were neither racist nor sexist? Might a family’s income affect us? What would stop us from imagining that babies with wealthier parents were more wanted?
That said, and though I disagreed with my partner generally, he had a point, sadly, about the baby being unwanted. The child, if she lived, would almost certainly enter foster care, where many of the babies bounce from home to home. Maybe she would be one of the lucky ones, adopted at an early age, but given her history, it was unlikely. Special needs children born to mothers who use drugs are not the most desired adoption candidates.
But there is one more tidbit of information about this case that might be relevant. The baby’s mother was Black. Had that influenced my white partner’s comment? I wondered. Neither he nor I thought we were racist, and I could not recall my partner ever having been overtly racist. At the time (this happened many years ago), we recognized that racism was an issue in our society, but we were not having the same prominent discussion we are having today about social determinants of health and systemic racism. We did not talk of implicit bias, racial or otherwise. We were not as “woke” as we are today, and, although there are likely still some physicians who agree with his assessment, I honestly wonder whether my partner could possibly have made the same comment today.
Whether the comment was racist or not, though, it illustrates the pitfalls we can encounter when we allow social standing to influence our decisions regarding patients. If we allow illicit drug use to affect our decisions, can using race be far behind?
It may feel surprising that we need to have this discussion today. Do I really have to point out that we shouldn’t treat poor patients differently from rich ones? Or Black patients differently than white ones? I would have thought this discussion unnecessary, but on the other hand, the events of the last several years suggest we are not as advanced as we might have hoped. There are still members of our society, including physicians, who consider particular populations — like drug users — less valuable. And unfortunately, there are times when we do have to allow social status to affect our decisions. You can’t send a person experiencing homelessness back home with peritoneal dialysis or home IV antibiotic therapy, for example.
Is consciousness of social standing in decision-making right? Probably not. Can it be prevented? Again, probably not. In our society there will always be “haves” and “have nots,” but – and again, I really think I shouldn’t have to say this — we should still do our best not to treat the two differently. Those of us in higher socioeconomic classes must never assume that we are better than people with less money or education. But realistically, it is so hard. Is it possible to really understand what it’s like to live wondering if you’ll have enough money to pay rent next month when you’re working as a doctor in the U.S.? I’d wager it's unimaginable for most physicians.
In this case, for my patient, we ended up recommending to the mother that life support be withdrawn. She agreed, we withdrew, and the baby died. I was the attending physician on service, so the final call to make the recommendation was mine, and I can assure you we removed life support for no reason other than because further treatment was futile. We did not weigh the baby’s social standing.
The mother came in when her baby died and genuinely grieved, weeping at the bedside. An unplanned baby with no place to go? Maybe. Unwanted? I don’t think so.
What factors do you think have no place in medical decision-making? Share your thoughts in the comments.
Paul Holtrop is a recently retired neonatologist who lives in northern Michigan. Besides trying to keep up with the medical literature, he enjoys bicycling and cooking, plus watching college football — except, of course, for the cringe-worthy head injuries. Dr. Holtrop is a 2021–2022 Doximity Op-Med Fellow.
Illustration by April Brust
