ETHICAL ISSUES IN NEWBORN

CARE

DR.SUBRAMANYAM.S
MODERATOR – DR.SNEHA
 BACKROUND

• Clinical situations with ethical implications are more difficult for

professionals and families.

• These include decisions regarding instituting, withholding, or

withdrawing life- sustaining therapy in patients with irreversible or
terminal conditions such as extreme immaturity, severe hypoxic–
ischemic encephalopathy, certain congenital anomalies.
 OBJECTIVES

• Respecting parental authority/autonomy

• Applying the best interests of the infant standard of judgment
• Minimizing harm to the new born
• Developing sound parent-physician relationships
• Empowering and informing parents
• Applying family-centered care principles
• Respecting parents’ values and cultural and religious beliefs
• Sharing decision making
• Developing respectful interprofessional (moral) teamwork
 PRINCIPLES OF ETHICAL CARE

Respect for
Beneficence
autonomy

FUNDAMENTAL ETHICAL PRINCIPLES

Non-
Justice
Maleficence
 PARENTAL AUTONOMY

• The principle of autonomy supports the right of competent patients to

make their own health care choices.

• Finding the right balance between respect for parental autonomy and
the physician’s role and responsibility in any decision-making process
requires insight, empathy, and great analytical and communication
skills.
 BENEFICENCE

• Beneficence is the obligation to “do good,” that is, to promote the best
interests of their patients.
• In new borns, this obligation is embodied in the concept of the “best
interests of the new born.”
 NONMALEFICENCE

• The principle of nonmaleficence implies an obligation not to inflict

harm on others. It has been closely associated with the maxim “primum
non no cere” (first do no harm).

• Nonmaleficence requires that no initiation or continuation of treatment

be considered without consideration of whether the treatment is overly
burdensome or harmful.
 JUSTICE

• Justice is the framework by which we determine how social benefits,

such as health care, and burdens, such as research risks, are
distributed.
• Treat equals equally.
• Fair allocation of scarce resource (NICU beds)
CASE SCENARIOS
CASE 1 :
• A female baby , 36 weeks delivered by caesarean section (polyhydraminos,
IUGR, previous LSCS) cried at birth. Baby had mild RDS and was supported
initially by NIV and echo done was s/o VSD(7mm) and was started on anti-
failure measures. I/v/o clinical suspicion karyotyping done was positive for
Edward syndrome. Parents were counselled regarding the prognosis and need
for long term oxygen requirement.

Ethical concern : Surgery was deferred i/v/o poor prognosis and

neurodevelopmental delay(GDD and MR) and long term oxygen requirement
requiring financial stability.
CASE 2 :

• A male baby 27 weeks delivered by caesarean section (eclampsia),

had weak cry at birth and was intubated on table. Baby had severe
RDS and was given surfactant and NSG was showing grade IV IVH.
Baby had stage 3 ROP and laser photocoagulation was done for the
same. Baby needed continuous oxygen support and CXR revealed
features of chronic lung disease. Parents were counselled regarding the
prognosis and requirement of continuous oxygen therapy.
CASE 3:
• A female baby, term born by NVD required hospitalization on the 6th
day due to difficulty in breathing and bluish discoloration of the body.
Diagnostic evaluation revealed complex cyanotic congenital heart
disease that was incompatible with life in the absence of immediate
therapeutic intervention. Prostaglandin infusion was initiated; parents
were asked to procure additional doses as the hospital supply was
limited. The parents were unable to afford the prostaglandin therapy.
Surgery was ruled out as an option both due to limited availability of
expertise as well as the requirement of considerable expenses on the
part of the parents. Consequently, they left the hospital against medical
advice.
CASE 4:

A female was born to a primigravida mother after 25 weeks of

gestation and weighed 490 grams. She developed severe respiratory
distress at birth; resuscitation at birth was withheld in view of remote
chances of survival, in concurrence to parental wishes. She was offered
only comforting care till she expired at the 4th postnatal hour.

Ethical issues: Decision to withhold resuscitation due to extreme

prematurity and potentially violating the “sanctity of life”; and, feasibil-
ity of providing prolonged intensive care in resource constrained settings.