Critical care decisions in fetal and neonatal medicine: ethical issues
Resources - Previous work in the area
The Institute of Medicine, US, has published a report, Preterm Birth: Causes, Consequences, and Prevention (2006), which notes disparities in preterm birth rates among different racial and ethnic groups. Despite improvements in the survival of infants born preterm, little is known about how preterm births can be prevented. The report recommends a multidisciplinary research agenda aimed at improving the prediction and prevention of preterm labor and better understanding the health and developmental problems to which preterm infants are more vulnerable. In addition, the report recommends that guidelines be issued to further reduce the number of multiple births - a significant risk factor for preterm birth - resulting from infertility treatments.
The National Service Framework for Children provides national standards for healthcare and social services across the NHS for all children.
The British Medical Association provides guidance for decision-making on Withholding and Withdrawing Life Prolonging Medical Treatment (2001) and expects the same ethical framework for the provision or continuation of treatment to apply to babies as for children, young people and adults. The guiding principle is that the treatment should be in the child’s best interests. Where there is reasonable uncertainty about the possible benefits of life-prolonging treatment, the BMA advises presumption in favour of initiating it. Criteria for determining a child’s best interests include whether the child has the potential to develop awareness, the ability to interact and the capacity for self-directed action, and whether the child will suffer severe unavoidable pain and distress.
The General Medical Council sets out standards of practice expected of doctors when they consider whether to withhold or withdraw life-prolonging treatments in Withholding and Withdrawing Life-prolonging Treatments: Good Practice in Decision-making (2002). The guidance is based on ethical principles which include doctors’ obligations to show respect for human life; protect the health of their patients; and make their patients’ best interests their first concern. Issues raised for consideration include: whether doctors should offer all means at their disposal to prolong a patient’s life; the circumstances in which withholding or withdrawing life-prolonging treatment would be unlawful; and the responsibilities in the decision-making process of the patient, doctor, healthcare team, family members and other people who are close to the patient.
The Royal College of Paediatrics and Child Health has issued guidance on Withholding or Withdrawing Life Saving Treatment in Children (1997). It distinguishes five situations where it may be ethical or legal to consider withholding or withdrawing life sustaining or curative medical treatment: the ‘brain dead’ child; the ‘permanent vegetative state’; the ‘no chance’ situation (where the child has such severe disease that life-sustaining treatment simply delays death without significant alleviation of suffering); the ‘no purpose’ situation (where the patient may be able to survive with treatment, but at a cost of severe physical or mental impairment); and, the ‘unbearable’ situation (where the child and/or family feel that in the face of progressive illness, further treatment is more than can be borne).
The British Association of Perinatal Medicine has published guidelines in the form of a memorandum entitled Fetuses and Newborn Infants at the Threshold of Viability: A Framework for Practice (2000). The guidelines recommend that decisions on management should be based on what is perceived by the parents and their medical advisors to be in the child’s best interests; medical staff have a responsibility to keep parents informed as to the likely clinical outcome of decisions and counselling must be honest and accurate. They emphasise the need, where possible, for advance liaison between members of the medical team and highlight the possibility of obtaining advance authorisation for non-resuscitation and non-provision of intensive care for infants at the extreme margins of viability.
Last Updated Fri, 15 December 2006