Harm and Uncertainty In Newborn Intensive Care

Abstract

There is a broadly held view that neonatologists are ethically obligated to act to override parental nontreatment decisions for imperiled premature newborns when there is a reasonable chance of a good outcome. It is argued here that three types of uncertainty undercut any such general obligation: (1) the vagueness of the boundary at which an infant's deficits become so intolerable that death could be reasonably preferred; (2) the uncertainty about whether aggressive treatment will result in the survival of a reasonably healthy child or, alternatively, the survival of a child with intolerable deficits; and (3) the inability to determine an acceptable ratio between the likelihoods of those two outcomes. It is argued that the broadly held view accords insufficient weight to the fact that newborn intensive care increases the likelihood of harm to the child by effecting survival with intolerable deficits. Though treatment may offer a reasonable chance of a good outcome, it is argued that there are situations in which neonatologists should nonetheless defer to parental nontreatment decisions.

In what circumstances will a neonatologist decide a patient is not a resuscitation candidate?

“…Determining that an infant's neurological prognosis and predicted quality of life are too poor to warrant CPR, without seeking parental agreement, requires giving precedence not only to the physician's medical judgement, but also to the physician's value judgements. It must be acknowledged that physicians’ prognostications about the level of disability are sometimes wrong, and that quality of life assessments are subjective 18 19. Thus, we share the intuition expressed by most neonatologists in this study, that a DNAR order without parental agreement, based solely on predicted neurological disability, would be inappropriate in nearly all cases.…”

Conflicts Between Parents and Health Professionals About a Child’s Medical Treatment: Using Clinical Ethics Records to Find Gaps in the Bioethics Literature

“…In the seventy-one cases overall, there were approximately equal numbers of cases involving parents refusing a recommended treatment path (e.g., Austin et al 2009;Boyle, Salter, and Arnander 2004;Kipnis 2007;Kopelman and Kopelman 2007;Rhodes and Holzman 2004) and cases involving parents seeking treatment against the doctors' recommendations (e.g., Carnevale 2005;Goldworth 2010;Jecker 2011;Jonas 2007;Opel and Wilfond 2009).…”

A Life Worth Giving? The Threshold for Permissible Withdrawal of Life Support From Disabled Newborn Infants

“…Although not expressing it in terms of asymmetrical harms, Kenneth Kipnis (2007) has also argued that the risk of an LNWL would justify allowing an infant to die.…”