Marten J. Poley - Erasmus Universiteit Rotterdam

Cost-Effectiveness of Neonatal Surgery: First Skepticized, Now Increasingly Accepted 111The 2000 review updatedWe updated the earlier review cited above 18 to see whether recent years havebrought more empirical results. We searched the literature from the year 1999onwards for complete economic evaluations of both diagnostic and therapeuticinterventions in neonatal surgery. In spite of the fact that we applied liberalcriteria for inclusion—several studies, for example, only evaluated postoperativecomplication rates rather than more advanced patient outcome measures—weidentified no more than 11 relevant studies, including our economic evaluations inARM and CDH referred to earlier. Even though our review covered just a fewyears and only included studies published in English, the conclusion can only bethat the number of published economic evaluations in the field of neonatalsurgery is still small. Table 7.1 details the interventions investigated in all thesestudies, differentiating between the six groups of congenital anomalies listed byRavitch and colleagues 30 and other conditions. The authors predominantly drawfavorable conclusions on cost-effectiveness. What attracts attention is that,leaving our studies on ARM and CDH out of consideration, all studies except one(dealing with circumcision) concentrated on particular novel aspects of treatmentor diagnosis. So, drawing more conclusions on the entire treatment process ofneonatal surgery, next to our studies on ARM and CDH, is not possible.7.4 IS THERE A ROLE FOR ARGUMENTS OTHER THAN COST-EFFECTIVENESS?Above, we argued that it is not necessarily unethical to consider costeffectivenessarguments. However, we feel it would be unethical indeed to basedecisions on how much priority to give to a particular health care procedure oneconomic grounds exclusively. In the case of neonatal surgery, crucial ethicalquestions arise for example when considering whether therapy should be offeredor perhaps withheld, which often involve life-and-death decisions. In the case ofchildren with serious birth defects, the 'best interest' of the child may justifywithholding or withdrawing life-prolonging surgical intervention. There may befundamental uncertainties as to the child's future development, or in somesituations, a life strongly burdened by disability and dependency on life-supportsystems may be the ultimate outcome. 31-33 Treatment modalities that mayinvolve such ethical dilemmas include ECMO, the care for extremely prematureinfants, and prenatal diagnosis and fetal surgery. 34-38 Apart from ethicalarguments, religious, cultural, aesthetic, or legal aspects need to be considered inneonatal surgery, such as a child's right to be free of intrusive unnecessarymedical and surgical procedures before having reached the age of full and legaldiscretion (e.g., neonatal circumcision 39 ).