- At the Lok Nayak Hospital, Delhi
To travel by auto-rickshaw through New Delhi is to understand the profound truths of the Yom Kippur liturgy, "Man's origin is dust and dust is his end, each of us is a shattered urn, grass that must wither, a flower that will fade. . . ." Each ride is a journey to the precipice. The drivers seem quite sane as you bargain for the fare, but once you crawl into the tiny rear seat and they maneuver the flimsy, top-heavy vehicle onto the expressway, you realize sanity is a thin veneer indeed. They weave in and out among other "autos," huge trucks, cows, crowded buses, and an occasional elephant. It's best not to look, but simply to pray. The trip prepared me well for the challenge of my visit to the Lok Nayak Hospital, where I had been invited to speak about bioethics to the neonatologists there.
Lok Nayak, a fourteen-hundred-bed public hospital, serves the most thickly populated areas of Old Delhi. Last year, doctors there cared for ten million outpatients, 360,000 emergency patients, and forty thousand inpatients.
Students and residents packed the conference room I entered. They looked bored but friendly. Not many Western visitors came to Lok Nayak.
I was introduced as an expert in bioethics. My host, the chief of neonatology, could not leave it at that. "Bioethics in America," he went on, "deals mostly with issues that are irrelevant to the situations we face in India. They talk and write about liver transplants or saving babies with Trisomy. Here, we are more concerned with resource allocation and public health interventions to lower infant and maternal mortality in the villages."
It was a curious speech, coming as it did from the head of neonatology. I took the bait. "I wonder whether the sorts of issues we struggle with are really so different," I said. "For example, one of the issues we deal with is trying to decide whether there's a birth weight cutoff below which we should not offer resuscitation and NICU care."
"We also struggle with that," the chief said, "but our world is different. Here, we seldom treat babies who weigh less than fifteen hundred grams or are less than thirty-two weeks. We have too many deliveries and not enough beds." He seemed oddly proud, in the way that some neonatologists in the States do when they tell me they never resuscitate babies younger than twenty-four weeks. That pride signals tough-minded realism, as opposed to the sentimental idealism that would allow less clear-eyed doctors to offer hopeless, harmful, and wasteful therapies to desperate parents.
"We also have birthweight cutoffs and struggle to find the right balance between prevention and crisis intervention," I told him. "The difficult issue is when babies are born right around the cutoff. It doesn't make sense to apply any criterion strictly or absolutely."
He agreed. "If a baby is less than fifteen hundred grams but small for gestational age, we will sometimes intubate."
The students were engaged by this discussion-especially, it seemed, because their champion had just lost a point. He recovered quickly, though. "But in America, you sometimes force treatment on babies, even if the parents don't want it," he said. "That would never happen here."
"Really," I said. "You mean that if a baby had an easily treatable condition but the parents wanted to take him home, you'd let them?"
"Of course," he said. "We don't have enough resources to treat the babies of parents who want them treated. Why would we waste them on babies whose parents don't want treatment?"
In Delhi, death didn't seem as unexpected-or as tragic-as it did in America. It was everywhere. It happened. It was part of the cycle. In the face of this, I understood the uselessness of the framework we've erected to protect the best interests of the child against even his parents. Yet it seemed like parents' desire for their babies to survive must be universal, innate.
"Do you ever face the opposite situation?" I asked. "You put a baby on...