A Question of Life

Doctors told Mark and Karla Miller their unborn daughter would face a life of pain and illness. Then, against the Millers' wishes, Woman's Hospital did everything it could to keep the newborn alive. Last month, after an extraordinary trial in a Houston co

Apparently, that was the conclusion reached by the Miller jury. But if, as Sydow contends, this was a precedent-setting case, what precedent has been set? Should doctors bow to the wishes of parents without fail? Even Sydow admits that if the Millers weren't so obviously motivated by concern for their daughter's future well-being, rather than their own convenience, he wouldn't have taken the case.

An underlying question never put to the Miller jury is why Woman's Hospital overrode Mark and Karla's wishes. Was it because Columbia/HCA had its eye on the Millers' $1 million in health-insurance benefits, as Sydow suggested in his closing argument? Or, as corporation lawyers contend, could Sidney's caregivers (and perhaps her parents) have been charged with child abuse -- or even murder -- if treatment had been withheld?

The birth of Sidney Miller also raises a broader issue that medical ethicists and practitioners are still trying to resolve: When do technological advances in treatment cross the line that separates progress from human experimentation?

Whatever the answers, they will not change Sidney's life. The child's doctors say that while Sidney will never improve, there is no reason she shouldn't live as long as the next woman. That possibility fills her parents with an incredible sadness.

"I can't think past tomorrow because it just breaks my heart," Karla Miller says. "I don't want anyone to hurt her or abuse her any more than she's already been hurt and abused. But there will be a day when we won't be able to care for her anymore."

"Once ... death was regarded as an act of Providence, often inscrutable. We are now coming to look upon a high infant death rate as evidence of human weakness, ignorance and cupidity. We believe that Providence works through human agencies and that in this field as in others, we reap what we sow -- no more and no less."

-- L. Emmett Holt, professor of diseases of children, in an address to the American Association for the Study and Prevention of Infant Mortality, November 1913

At the time of Emmett Holt's address, a Dr. Martin Couney was drawing thousands of gawkers to "incubator-baby sideshows," and many people still reasoned that the death of sick or premature infants gleaned the weakest from the human race, and therefore was good for society.

The standards of medical care were scarcely more advanced. As recently as a generation ago, the chances were slim that a newborn with a very low birth weight -- less than three and a half pounds -- would live out the day. Survivors were often subjected to treatment that did more harm than good. Until the 1960s, doctors routinely withheld early feeding from such infants, leading to dehydration and hypoglycemia. Blindness resulted from excessive oxygen therapy, and antibiotics such as streptomycin caused deafness. Two out of three babies born in this weight category were developmentally impaired.

Major advances in prenatal obstetrics and newborn intensive care during the '60s and '70s increased the survival rate of infants weighing as little as two pounds, who almost without exception entered the world prematurely. Meanwhile, the incidence of major handicaps such as cerebral palsy decreased.

By the time Karla Miller learned she was pregnant in the spring of 1990, high-tech neonatal intensive care units (NICUs) were using cesarean section, mechanical resuscitation, drug therapies and other aggressive life-support techniques to save infants born at lower weights and younger gestational ages. But studies done in the 1980s suggested that progress had its price.

Researchers noted a rise in cerebral palsy, blindness and mental retardation directly linked to the improved survival rates of low birth-weight infants, triggering the question of whether aggressive neonatal treatment merely prolongs suffering in cases where withholding that care might be a more compassionate option.

Like all prospective parents, Mark and Karla Miller were anxious about the birth of their first child. Bright, educated and reasonably affluent, they knew the importance of, and could afford, good prenatal care. On the recommendation of a friend, Karla chose Dr. Mark Jacobs as her obstetrician, and he arranged a regular schedule of checkups. The first trimester of Karla's pregnancy was uneventful, and neither doctor nor patient had any reason to expect complications.

On the afternoon of August 16, Karla felt very tired. Mark had a social function to attend that evening, so she went to bed early. Shortly before 2 a.m., Karla awoke for the second time that night with abdominal pain. After noticing traces of blood in her urine, she called Jacobs.

"I think I might be in labor," she told her doctor.
"It's too early for labor," Jacobs replied, "but it sounds like you may be trying to get rid of the baby."

Jacobs told her to go to Woman's Hospital of Texas, where the doctor practiced and Karla was preadmitted. By the time she and Mark arrived, Karla's cramps had intensified.

The resident on call discovered that Karla's cervix had dilated three centimeters and that her amniotic sac, the cushion of fluid that protects the fetus in the womb, was bulging. Karla was in preterm labor -- the worst possible news at this early stage of fetal development. After consulting by phone with Jacobs, the resident told the Millers about terbutaline, a drug developed for asthma sufferers that relaxes the smooth muscles of the sinuses. Because the uterus is also a smooth muscle, terbutaline is sometimes effective in easing labor contractions.

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