Saving or Creating: Which Are We Doing When We Resuscitate Extremely Preterm Infants?

The Ethics and Practice of Periviability Care

Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...].

What You're Rejecting When You're Expecting

I defend two collapsing or reductionist arguments against weak pro-natalism (WPN), the view that procreation is generally merely permissible. In particular, I argue that WPN collapses into strong pro-natalism (SPN), the view that procreation is generally obligatory. Because SPN conflicts with the dominant view that procreation is never obligatory, demonstrating that WPN collapses into or entails SPN establishes epistemic parity (at least as concerns reproductive liberty) between WPN and anti-natalism (AN), the view that procreation is always impermissible. First, I distinguish between two moral goods: the good of procreation itself and the good of procreative potential. Second, I contend that the average moral agent is obligated to assist needy children via adoption, fostering, or other financial or interpersonal support. Third, I present the first collapsing argument: if an agent's justification for not assisting needy children is preservation of their resources (financial or interpersonal) for their actual future offspring, that justification is preserved only if they eventually and actually procreate. Thus, their eventual procreation is morally obligatory and SPN follows. Fourth, I present the second collapsing argument, which assumes procreative potential as the relevant good: if an agent's justification for not assisting needy children is preservation of their resources for their potential future offspring, that justification holds only if (a) the objective or subjective valuation of the opportunity is of the relevant type and valence to justify not assisting needy children and (b) the agent sincerely values the opportunity. Fifth, I argue that (a) is unsatisfied and that while (b) is satisfied in most cases, it entails that most agents are obligated to desire or be behaviourally disposed to pursue procreation for themselves (i.e., SPN). Thus, I conclude that both actual procreation and procreative potential are either insufficient justifications for not assisting needy children or that they entail obligatory pro-reproductive attitudes or behaviours.

Regulating abortion after ectogestation

A few decades from now, it might become possible to gestate fetuses in artificial wombs. Ectogestation as this is called, raises major legal and ethical issues, especially for abortion rights. In countries allowing abortion, regulation often revolves around the viability threshold-the point in fetal development after which the fetus can survive outside the womb. How should viability be understood-and abortion thus regulated-after ectogestation? Should we ban, allow or require the use of artificial wombs as an alternative to standard abortions? Drawing on Cohen, I evaluate three possible positions for the post-ectogestative abortion laws: restrictive, conservative and liberal. While the restrictive position appears untenable, I argue that the liberal and conservative positions can be combined to form a legally and morally coherent basis for post-ectogestative abortion legislation, offering an improvement from the point of both prolife and prochoice positions.

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.

Clinical challenges to the concept of ectogestation

Since the publication of the successful animal trials of the Biobag, a prototypical extrauterine support for extremely premature neonates, numerous ethicists have debated the potential implications of such a device. Some have argued that the Biobag represents a natural evolution of traditional newborn intensive care, while others believe that the Biobag would create a new class of being for the patients housed within. Kingma and Finn argued in Bioethics for making a categorical distinction between fetuses, newborns and 'gestatelings' in a Biobag on the basis of a conceptual distinction between ectogenesis versus ectogestation. Applying their arguments to the clinical realities of newborn intensive care, however, demonstrates the inapplicability of their ideas to the practice of medicine. Here, I present three clinical examples of the difficulty and confusion their argument would create for clinicians and offer a possible remedy: namely, discarding the term 'artificial womb' in favour of 'Biobag'.

An e-Delphi study on mode of delivery and extremely preterm breech singletons

OBJECTIVES

To understand clinicians' consensus on mode of delivery in extremely preterm breech infants; assess knowledge on neonatal outcomes and its impact on consensus.

STUDY DESIGN

A two-round Delphi of obstetrical or neonatal care providers, recruited from national conferences and investigator networks. Round one assessed decision-making (vignettes), and knowledge; the second round reassessed vignettes after presenting outcome data.

RESULTS

In round one (102 respondents), consensus (a priori, ≥75% agreement) was achieved in 4/13 vignettes: two when likely/very likely to offer Cesarean (26 and 27 weeks) and two for unlikely/very unlikely (23 weeks growth restriction, ± adverse features). Clinicians generally underestimated neonatal outcomes. In round two (87 respondents), three scenarios achieved consensus (likely/very likely to offer Cesarean at 25-27 weeks); in five other vignettes, not offering Cesarean was reduced in ≥15% of respondents.

CONCLUSION

Limited consensus exists on extremely preterm breech mode of delivery, partly associated with neonatal outcome underestimation.

GESTATIONAL AGE NOTATION

The authors follow the World Health Organization's notation on gestational age. Under this notation, the first day of the last menstrual period (LMP) is day 0 of week 0. Therefore, days 0-6 represent completed week 0, days 7-13 represent completed week 1 and so on.

Postponed Withholding: Balanced Decision-Making at the Margins of Viability

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.

Ethical implications of the shifting borderline of viability

Survival rates for babies born at 22 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. Thus, parents will be given very different advice at different centers for babies born at the borderline of viability. Those doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Yet there is strong evidence that many babies born at 22 weeks can survive, most survivors have good neurodevelopmental outcomes, and neonatal intensive care for tiny babies is cost-effective compared to many common and uncontroversial treatments. Given this growing body of evidence, policies discouraging or forbidding treatment of babies born at 22 weeks will require stronger ethical justification than has been given to date.

Ethical issues in treatment of babies born at 22 weeks of gestation

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies.

Conventional revolution: the ethical implications of the natural progress of neonatal intensive care to artificial wombs

Research teams have used extra-uterine systems (Biobags) to support premature fetal lambs and to bring them to maturation in a way not previously possible. The researchers have called attention to possible implications of these systems for sustaining premature human fetuses in a similar way. Some commentators have pointed out that perfecting these systems for human fetuses might alter a standard expectation in abortion practices: that the termination of a pregnancy also (inevitably) entails the death of the fetus. With Biobags, it might be possible, some argue, that no woman has the right to expect that outcome if the technology is able to sustain fetal life after an abortion. In order to protect the expectation that the termination of a pregnancy always entails the death of the fetus, Elizabeth Romanis has argued that fetuses sustained in Biobags have a status different than otherwise 'born' children. In support of that view, she argues that these 'gestatelings' are incapable of independent life. This argument involves a misunderstanding of the gestational support involved, as well as a misapprehension of neonatology practice. Here, we argue that any human fetus sustained in a Biobag would be as 'independent' as any other premature infant, and just as 'born'. Neonatologists would seem to have certain presumptive moral responsibilities toward any human fetus gestating in a Biobag. It remains a separate question whether the perfection and widespread application of Biobags for premature human beings would or should alter the expectation that ending a pregnancy also entails fetal death.

Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis?

In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.

Ethics of resuscitation for extremely premature infants: a systematic review of argument-based literature

OBJECTIVE

To present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts.

DESIGN

We conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation.

ANALYSIS

After repeated reading of articles, we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed.

RESULTS

Forty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision.

CONCLUSIONS

The included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents' decision should be over-ridden when in contrast with the EPI's best interest.

The Extremely Preterm Infant: Ethical Considerations in Life-and-Death Decision-Making

Care of the preterm infant has improved tremendously over the last 60 years, with attendant improvement in outcomes. For the extremely preterm infant, <28 weeks' gestation, concerns related to survival as well as neurodevelopmental impairment, have influenced decision-making to a much larger extent than seen in older children. Possible reasons for conferring a different status on extremely preterm infants include: (1) the belief that the brain is a privileged organ, (2) the degree of medical uncertainty in terms of outcomes, (3) the fact that the family will deal with the psychological, emotional, physical, and financial consequences of treatment decisions, (4) that the extremely preterm looks more like a fetus than a term newborn, (5) the initial lack of relational identity, (6) the fact that extremely preterm infants are technology-dependent, and (7) the timing of decision-making around delivery. Treating extremely preterm infants differently does not hold up to scrutiny. They are owed the same respect as other pediatric patients, in terms of personhood, and we have the same duties to care for them. However, the degree of medical uncertainty and the fact that parents will deal with the consequences of decision-making, highlights the importance of providing a wide band of discretion in parental decision-making authority. Ethical principles considered in decision-making include best interest (historically the sine qua non of pediatric decision-making), a reasonable person standard, the "good enough" parent, and the harm principle, the latter two being more pragmatic. To operationalize these principles, potential models for decision-making are the Zone of Parental Discretion, the Not Unreasonable Standard, and a Shared Decision-Making model. In the final analysis shared decision-making with a wide zone of parental discretion, which is based on the harm principle, would provide fair and equitable decision-making for the extremely preterm infant. However, in the rare circumstance where parents do not wish to embark upon intensive care, against medical recommendations, it would be most helpful to develop local guidelines both for support of health care practitioners and to provide consistency of care for extremely preterm infants.

Protect us from ourselves: Balancing the parental instinct of saving

BACKGROUND

Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable?

RESEARCH QUESTION

In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether to provide lifesaving treatment when their child is born at the limit of viability?

RESEARCH DESIGN

We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014-2018.

ETHICAL CONSIDERATIONS

All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study.

FINDINGS

We identified six main themes in parents' responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief.

CONCLUSION

The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for 'everything to be done'. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child.

Artificial womb technology and the frontiers of human reproduction: conceptual differences and potential implications

In 2017, a Philadelphia research team revealed the closest thing to an artificial womb (AW) the world had ever seen. The 'biobag', if as successful as early animal testing suggests, will change the face of neonatal intensive care. At present, premature neonates born earlier than 22 weeks have no hope of survival. For some time, there have been no significant improvements in mortality rates or incidences of long-term complications for preterms at the viability threshold. Artificial womb technology (AWT), that might change these odds, is eagerly anticipated for clinical application. We need to understand whether AWT is an extension of current intensive care or something entirely new. This question is central to determining when and how the biobag should be used on human subjects. This paper examines the science behind AWT and advances two principal claims. First, AWT is conceptually different from conventional intensive care. Identifying why AWT should be understood as distinct demonstrates how it raises different ethico-legal questions. Second, these questions should be formulated without the 'human being growing in the AW' being described with inherently value laden terminology. The 'human being in an AW' is neither a fetus nor a baby, and the ethical tethers associated with these terms could perpetuate misunderstanding and confusion. Thus, the term 'gestateling' should be adopted to refer to this new product of human reproduction: a developing human being gestating ex utero. While this paper does not attempt to solve all the ethical problems associated with AWT, it makes important clarifications that will enable better formulation of relevant ethical questions for future exploration.

Neonatal nurse practitioner ethics knowledge and attitudes

BACKGROUND

Neonatal nurse practitioners have become the frontline staff exposed to a myriad of ethical issues that arise in the day-to-day environment of the neonatal intensive care unit. However, ethics competency at the time of graduation and after years of practice has not been described.

RESEARCH AIM

To examine the ethics knowledge base of neonatal nurse practitioners as this knowledge relates to decision making in the neonatal intensive care unit and to determine whether this knowledge is reflected in attitudes toward ethical dilemmas in the neonatal intensive care unit.

RESEARCH DESIGN

This was a prospective cohort study that examined decision making at the threshold of viability, life-sustaining therapies for sick neonates, and a ranking of the five most impactful ethical issues.

PARTICIPANTS AND RESEARCH CONTEXT

All 47 neonatal nurse practitioners who had an active license in the State of Mississippi were contacted via e-mail. Surveys were completed online using Survey Monkey software.

ETHICAL CONSIDERATIONS

The study was approved by the University of Mississippi Medical Center Institutional Review Board (IRB; #2015-0189).

FINDINGS

Of the neonatal nurse practitioners who completed the survey, 87.5% stated that their religious practices affected their ethical decision making and 76% felt that decisions regarding life-sustaining treatment for a neonate should not involve consultation with the hospital's legal team or risk management. Only 11% indicated that the consent process involved patient understanding of possible procedures. Participating in the continuation or escalation of care for infants at the threshold of viability was the top ethical issue encountered by neonatal nurse practitioners.

DISCUSSION

Our findings reflect deficiencies in the neonatal nurse practitioner knowledge base concerning ethical decision making, informed consent/permission, and the continuation/escalation of care.

CONCLUSION

In addition to continuing education highlighting ethics concepts, exploring the influence of religion in making decisions and knowing the most prominent dilemmas faced by neonatal nurse practitioners in the neonatal intensive care unit may lead to insights into potential solutions.

NICU Dialects: Understanding Norwegian Practice Variation

In Norway, a national consensus-based guideline used to address thresholds for offering life support at extreme preterm birth was issued in 1998. Since then, therapeutic advances may have changed attitudes and expectations to treatment, both within the medical community and the public, and there are concerns that systematic variations in treatment practices may exist. With this article, we describe current practices and relate them to other ethical and legal comparable areas in health care. We conclude that a revision of the 1998 guideline is warranted to obtain a common understanding of prognoses and appropriate decision processes at the limit of viability.

In Search of Consistency: Scandinavian Approaches to Resuscitation of Extremely Preterm Infants

Guidelines around the resuscitation of extremely preterm infants have been developed, in part, to ensure consistency in decision-making between hospitals and health professionals. However, such guidelines can also be used to highlight other forms of inconsistency: between countries and between practices in different areas of medicine. In this article, we highlight the ethical advantages (and disadvantages) of consistency. We argue that an internationally uniform approach to ethically complex decisions is neither likely nor desirable.