Critical care decisions in fetal and neonatal medicine: ethical issues
Proposed criteria for judging best interests
27 A more transparent and structured set of criteria for judging the best interests of a baby may be helpful to parents and doctors. We suggest below some criteria, for consideration by the Royal Colleges, and recommend that these, or similar criteria, should become part of good clinical practice (paragraphs 9.32–9.34).
28 When a decision must be made by doctors whether or not to institute life support and ventilation immediately after birth, the following points should be considered in assessing the best interests of a baby. This assessment should be made in the light of the guidelines for instituting resuscitation and full intensive care proposed at paragraph 9.16:
(a) The gestational age of the baby at birth.
(b) The evidence available indicating the likelihood of survival and incidence of severe disability among babies born at that gestational age.
(c) The evidence available from the initial assessment on:
(i) the baby’s vitality at birth; and
(ii) any significant abnormalities.
(d) The views and feelings of the parents, in the light of that evidence, and accorded the significance proposed above.
29 When a decision must be made whether or not to institute or to withhold further treatment from a baby after birth, the following questions should be considered:
(a) To what extent is it likely that the treatment in question will effect a significant prolongation of the child’s life? (It will not generally be in the interests of the baby to prolong the process of dying.)
(b) What degree of pain, suffering and mental distress will the treatment in question inflict on the baby? Will there be a need for repeated, painful and distressing medical interventions? What measures can be taken to ameliorate any pain, suffering and distress?
(c) What benefits will accrue to the future child from treatment in question, for example?
(i) Will the child at any stage be able to survive independently of life support?4
(ii) Will treatment increase the chance that the child will be able to be cared for out of hospital?
(iii) Will the child be likely to be capable of establishing relationships with other people?
(iv) Will the child be likely to be able to experience pleasure of any kind?
(d) Then, in the light of evidence regarding a–c:
(i) Do the burdens of treatment outweigh the benefits?
(ii) What kind of support is likely to be available to provide the optimum care for the child?
(e) The views and feelings of the parents as to the interests of the baby, especially in relation to (d).
In the rare case that a baby either has no parents or has been taken into care, the local authority will often be able to exercise parental responsibility in relation to that child. However, it is important to be assured that the baby’s interests are properly represented. This may be a case that would benefit from early referral to a clinical ethics committee (see paragraphs 9.37–9.39).
30 When a decision must be made whether or not to withdraw life-sustaining treatment from a baby with a limited prognosis, the following questions should be considered:
(a) For how much longer is it likely that the baby will survive if life-sustaining treatment is continued?
(b) What evidence is there that the baby is experiencing pain, suffering or distress? What measures are being, or could be taken, to ameliorate that pain, suffering or distress?
(c) Is it likely that, if life-sustaining treatment is continued, the baby will ever be able to survive independently of life support?5
(d) What benefits accrue to the baby from continuing life-sustaining treatment?
(i) Is he or she able to establish relationships with other people? Does he or she react to his or her surroundings?
(ii) Does he or she experience pleasure of any kind?
(e) In the light of this evidence:
(i) Do the burdens of continued life support outweigh any benefits?
(ii) Does the baby exhibit signs of effort to survive?
(f) The views and feelings of the parents as to the interests of the baby, especially in relation to (e) above.
Footnotes
4 We note that with appropriate care, children on long-term ventilatory support can be discharged from hospital.
5 As footnote 4 above.