The Premature Lottery in the Canadian Grey Zones
Prakesh S. Shah.
Canada is a large country with only 34 million inhabitants. Canada has a socialized healthcare system and a
prematurity rate between 7 and 8%. Interventions for extremely low gestational age infants (ELGANs) raise ethical concerns
in many countries. Unlike the physiologic limit of viability, which is about 22 weeks and is similar around the
globe, the borders of the “grey zone” for ELGANs range between 21 to 26 weeks, depending where the baby is born. The
borders of the gray zones are fuzzy, elastic and subjective. We will explore variation of practice for ELGANs both around
the world and in Canada. We will come to several conclusions 1. Policy statements for ELGANs based uniquely on gestational
age are scientifically problematic and should be avoided; 2. Policy statements for ELGANs might reflect the fact
that ELGANs are considered to be morally different from older children; 3. Variation of practice (and outcomes) for ELGANs
may reflect values more than facts, and facts in turn can influence values; 4. National databases, such as the Canadian
Neonatal Network, are invaluable tools in evaluating and studying variation of practices for ELGANs; 5. Physicians
can learn from these variations of practice, but this demands humility, curiosity and open mindedness; 6.The increase in
preterm birth rates should be seen as an emergency in all countries.
Keywords: Extreme prematurity, ethics, health care practices, resuscitation, end-of-life decisions
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