[quote][url=http://www.nuffieldbioethics.org/go/ourwork/prolonginglife/page_260.html]Introduction and aims
The Chairman of the Nuffield Council welcomed the group and thanked them for attending. The aim of the Workshop was to provide guidance for the Council on whether the topic of prolonging life in fetuses, neonates and adults was one that should be considered by the Council in more detail.
Prolonging life in fetuses and the newborn
A combination of factors relating to healthcare, law and culture in the UK had led to problems in clinical decision-making about prolonging life in the fetus. Three parties were involved in fetal medicine – health professionals, parents and the fetus.
There had been significant advances in the treatment and healthcare of the newborn over the past century, but this had not always been matched by an increase in ability to make accurate predictions about the development of disease or the chances of recovery. The age at which fetuses were viable had reduced to as little as 23 weeks. However, extremely premature babies were at risk of lung disease, brain injury, infection and blindness. Actual risk levels of disability in premature babies had been difficult to define and apply because by the time the children had grown up treatments had improved and the risks were not the same. Also, it was difficult to take decisions on the basis of percentages and statistics, since it was never certain what would happen in an individual case.
[b]Several arguments for the selective use of neonatal intensive care (NIC) could be put forward:
– NIC might be worse than death because of the pain and suffering it would cause;
– it might be futile, in the sense that the baby was very likely to die anyway;
– the prospects for the baby’s quality of life later on could be very poor; and
– considerations of cost and the allocation of limited resources might mean that NIC was not possible. [/b]
Ideally, the parents and the physicians should agree on the course of treatment. There was no agreement on whether doctors should resuscitate babies against the wishes of parents. Different physicians and parents would have varying views about whether resuscitation should be attempted. The responsibility of the parents for raising the child gave weight to the argument that the parents’ decision should be respected.
There was some discussion of the impact of assisted reproduction on the number of premature babies born. IVF (in vitro fertilisation) had increased the likelihood of premature births indirectly because of the greater number of multiple pregnancies. Other technologies, such as ultrasound and magnetic resonance, were being developed in an attempt to improve the ability to make an accurate prognosis in individual cases. However, further research was needed in all these cases.
The BMA recognised that the same moral duties were owed to babies as to adults and that the criterion in considering treatment was the baby’s best interests. An assessment of the benefits and burdens of treatment should not be separated from that criterion. Workshop participants discussed the legal and ethical issues involved in making decisions about withholding treatment, including the burden of future treatment, the costs and benefits of treatment across a whole lifetime, the difficulties of substituted judgement, and issues surrounding intent.
[b][i]Participants agreed that there had not been extensive consideration of the role of the family and the wider social consequences of prolonging the lives of fetuses and neonates.
The question of whether very premature babies and fetuses suffered and felt pain was raised. It was difficult to know whether another organism was feeling pain, but there was some evidence that fetuses mounted hormonal stress responses to painful interventions such as needle puncture.[/i][/b]
There was some discussion about the difference in the legal approach to a 23 week old fetus compared to a 23 week old premature baby. It was suggested that the difference was not justified due to the scientific evidence of a continuum of development, although another view was that the moment of birth did matter in social terms.
Participants discussed the place of social decision-making compared to clinical decision-making in terms of allocation of resources and who should be involved. There was consensus that, whoever decided, the process of decision-making should be honest and open, and there needed to be room for flexibility in individual cases.
The morning’s discussion was summed up by the Chairman, who identified several issues that had emerged:
– drawing a dividing line between the fetus and the neonate;
– the paucity of empirical research on which to base decisions in some areas;
– the need to be wary of terminology, for example the use of ‘rights’ of parents and children;
– the realities of involving parents in decisions about their children;
– the question of suffering in fetuses and neonates; and
– social issues regarding resource allocation[/url].[/quote]
Some of the issues from the original source.
Bodo