Discussion – Neonatal, Child & Women’s Issues
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Assignment Details:
Choose one of the following case studies, read the rubric for this assignment. You then will answer the accompanying questions to your ONE chosen case study and post your answer-viewpoints to the discussion board. Also please respond to at least one of your classmates posts within the first 24hrs of the assignment due date to encourage discussion.
Case Study #1: Critically Ill Newborns
The newborn intensive care unit (NICU) is a common setting for difficult ethical challenges, often involving life-and-death decisions. These may include withholding treatment such as resuscitation, mechanical ventilation, or surgery, or withdrawing life-sustaining medical treatment such as mechanical ventilation and artificial nutrition and hydration. Such decisions are frequently faced because of the high morbidity and mortality of some conditions commonly encountered in this setting, such as extreme prematurity, perinatal asphyxia, and major congenital anomalies. Who should decide when a treatment should be withheld or withdrawn? Ideally, decisions are made by the parents, providers, and nurses working together, but what is to be done when they disagree? On what basis should decisions be made? Ideally, a careful ethical analysis is carried out, based on solid clinical and prognostic data and the values of those involved in making the decision. In reality, data are often very vague and values are often not shared in common, but a decision must nevertheless be reached.
Such critical ethical decisions may be more common in the NICU than in other pediatric settings, but they are certainly not unique to the NICU. Nonetheless, is there something unique about ethical problems encountered with this patient population? For example, is borderline viability based on extreme prematurity a unique situation in pediatrics, or is it analogous to other problems sometimes encountered in the care of older children? Are clinicians more willing to withdraw or withhold life-sustaining treatment for this patient population than for others in pediatrics or adult medicine? If so, is this justified?
A 36-year-old woman who has been pregnant 3 times but has no living children presents to the hospital in active labor and ruptured membranes at 22 weeks and 5 days’ gestation. The fetus is a female singleton, the product of in vitro fertilization. Pregnancy was otherwise unremarkable, including several normal ultrasounds. Estimated fetal weight is 530 grams. On physical examination the cervix is dilated and the obstetrician believes that delivery will occur within the next several hours. The pediatric team meets with the woman and her husband to share information, answer questions, and discuss the plan.
1. What options should be offered to the parents for resuscitation and treatment?
2. If informed parents request resuscitation and intensive care but the clinical team feels they are inappropriate, is the team nevertheless obligated to provide it?
3. If informed parents decline resuscitation and intensive care measures but the clinical team feels it is inappropriate to withhold those measures, is the team nevertheless obligated to withhold those treatments?
4. What ethical principles or approaches can be applied to guide clinicians and parents through the care provided to this child?
Case Study #2: Maternal-Fetal Conflict
Pregnancy is a unique circumstance in medical ethics because of the absolute requirement to access the fetus only through intervention on the pregnant woman. Increasingly, as medical advances have offered the promise of therapy to the fetus, fetal interests have been considered separately from maternal interests by clinicians, policy makers, and the bioethics community. This is a somewhat artificial distinction, as usually maternal and fetal interests are aligned, and care of the fetus is intertwined with and dependent on care of the pregnant woman.
When conflict arises between maternal and fetal interests (eg, treatment of cancer during pregnancy that may result in fetal demise), a variety of ethical frameworks may be useful to consider for conflict resolution and decision-making. Helpful theoretical approaches include case-based analysis, the ethics of care, feminist theory, and traditional ethical principlism that uses the framework of autonomy, beneficence and nonmaleficence, and justice. In addition, societal and practitioner values can elevate emotionally laden issues of obstetric conflict and benefit from a comprehensive, thoughtful analysis from a variety of perspectives.
Different theoretical approaches all agree with the importance of promoting the autonomy and bodily integrity of the pregnant woman, ensuring that she has the information to provide a fully informed consent that is consistent with her values regarding pregnancy outcome.
In cases in which her decision may harm her fetus, coercion to force treatment is never justified. In extraordinary cases, legal intervention has been attempted. Using the courts to enforce treatment compliance by pregnant women has frequently been unsuccessful or has activated processes that are hasty and incomplete, and such court rulings are frequently overturned on appeal. Evidence shows that continuing a trusting, compassionate, professional relationship with the pregnant woman generally results in greater success in improving maternal and child health. Feminist ethics perspectives can help detect subtle, gender-based biases in clinicians’ approaches to conflict resolution and support collaborative decision-making for the pregnant woman and her health care team.
Jesse is a 24-year-old who presents in active labor with no prenatal care. The fetus appears to be term, quite large, and at risk for dystocia. Jesse is told that a cesarean birth is the best route of delivery for the fetus’ well-being. She declines the operation and requests a natural childbirth. Although the fetus begins to have heart rate deceleration consistent with fetal distress, Jesse continues to decline the recommended cesarean delivery.
1. Does the provider have an ethical obligation to intervene on behalf of the fetus as a patient?
2. What are the best interests of the pregnant woman and how are they determined?
3. What are the best interests of the fetus and how are they determined?
4. What ethical considerations, other than best interests, can inform the decision-making process?
5. Can the pregnant woman refuse the recommended treatment, particularly if harm is expected to come to the fetus?
