Good Example Of News Article Commentary Article Review

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Introduction. Withdrawal of life-saving treatment can be a difficult ethical problem in high-risk newborns. Though UK and Ireland legal and good practice frameworks allow withdrawal in certain situations, in practice these decisions often present complex dilemmas for the clinicians of the hospitals’ neonatal units. They require implementation of series of steps to ensure the decision is made without overriding the main ethical principles. The article reviewed deals with one of the cases of life-saving treatment withdrawal from a severely impaired newborn and the related ethical issues.
Article review. The article of Healy (2015) dwells upon the story of an Irish baby boy who suffered severe brain damage as a result of the complicated delivery by an emergency Caesarean Section procedure from 39-weeks pregnant mother who suffered a sudden cardiac arrest. The mother died shortly after the delivery (treatment withdrawal due to the critical state) and the boy was kept on ventilator due to the absence of respiratory activity. The severe brain encephalopathy led the doctors to the conclusion the boy would not survive the neonatal period of 28 days and even given 10% chance that he did he would be severely physically and mentally impaired. The weight of poor prognosis was enhanced by the quality of life of the boy which had been very low from the very delivery: he had been experiencing pain and kept on morphine. Based on these factors, the hospital took decision to withdraw a life-sustaining treatment from the baby but as his parents were not married, the court order was necessary in accordance with Irish legislation. The judge acceded to the hospital’s application, and the treatment was withdrawn after both the relatives had expressed their consent and the father had named the baby.
Ethical and legal dilemmas. Royal College of Pediatrics and Child Health (RCPCH) and British Association of Perinatal Medicine (BAPM) introduce three criteria to simplify the process of withdrawal justification for a clinician - “futile”, “burdensome” or not “in the child’s best interests” (RCPCH, 2004; BAPM, 2010). But even in presence of the formal guidance, the controversies of the basic concepts underlying withdrawal decisions can lead to the ethical conflicts. First, as each person has an inherent right to life, the sanctity of life as a greatest value is opposed to the quality of life (Nuffield, 2006). Second, neonates lack capacity to express the opinion and the conflict between the child’s best interests\beneficence and parents’ autonomy can arise. Third, the parents’ view can be different from that of the clinicians leading again to the conflict between autonomy and beneficence.
Clinicians often use the concept of “futility” evaluating it as zero or close to zero probability of the outcomes’ improvement as a result of the treatment (Madden, 2002). However in cases when the court order is required to implement the decision on treatment withdrawal, Irish courts try to avoid the term “futility” as a subjective notion based only on the clinicians’ opinion, with probability of conflict between the parents’ autonomy and the child’s beneficence remaining high. Instead, they focus on “intolerability” and “best interest” concepts (Madden, 2002), following the procedure described in the article. To evaluate the state of the patient, two classifications are taken into consideration by the court: the one of RCPCH outlining 5 clinical situations where LST withdrawal is permissible (“brain ‘dead” ,” permanent vegetative state “ ,“no chance” ,“no purpose”, “unbearable”) (RCPCH,2004) and the other of BAPM, with 3 groups of circumstances allowing withdrawal (”no chance”, “no purpose”, “unbearable”) (BAPM,2010). Those both have much in common, and the baby boy situation clearly presented a “brain dead”\“no chance” situation. Ethically, this position is most favorable for taking the decisions as the clinician’s opinion on obvious futility of treatment and the prognosis of limited survival normally leads to the consent of the parents or guardians to withdraw the treatment, as it happened with the boys’ relatives. The decision was taken in line with all ethical principles and the informed consent was taken from the relatives. Another most important thing corroborating the evidence the hospital dealt ethically, was observation of all end-of-life care principles in relation to the boy, as withdrawal of care should never interfere with them, for the sake of the patient’s beneficence and non-maleficence. Palliative continuation of comfort care by morphine administration for pain management was provided to the boy from the moment the doctors came to the conclusion he had been experiencing pain. In administering morphine to a newborn, the clinicians could have been faced with another ethical controversy such as doctrine of double effect where the action aimed at the patient’s comfort (opioids for pain relief) could have caused a harmful effect (respiratory depression). However as BAPM (2010) states every measure prescribed in the name of the patient’s beneficence, dignified and peaceful death and not with a deliberate intention to hasten this death, is ethical and legal, the decision to administer the morphine for the relief of the pain the baby was experiencing due to the severe brain damage, was ethical. The hospital put particular emphasis on holistic assessment of the family’s needs, having given the father a possibility to name (and possibly to hold) the baby before the treatment withdrawal. That shows that the end-of-life care plan for the baby was implemented and the withdrawal took place in compliance with ethical principles, also in respect to the patient’s privacy and confidentiality (Nuffield, 2006).
Conclusion. Though withdrawal of life-saving treatment in neonates can be difficult and may lead to ethical conflicts between beneficence\non-maleficence of the patient and parents’ autonomy, it is appropriate in certain clinical situations. The case of a newborn baby boy with severe perinatal encephalopathy described in the article of Healy (2015) illustrates a classic “no chance” situation and demonstrates that withdrawal of life-saving treatment can be made in appropriate manner from both ethical and legal point of view. The observation of palliative care principles and the holistic assessment of the family needs allowed the clinicians to withdraw the treatment in compliance with the child’s best interests and key concepts of end-of-life care.

References

1. British Association of Perinatal Medicine (BAPM) (2010). Palliative Care (Supportive and End of Life Care). A Framework for Clinical Practice in Perinatal Medicine. Retrieved from: http://www.bapm.org/publications/documents/guidelines/Palliative_Care_Report_final_%20Aug10.pdf
2. Healy, T. (2015, January 15). Dublin maternity hospital secures order to withdraw life-saving treatment from newborn baby boy. Independent.ie. Retrieved from: http://www.independent.ie/irish-news/dublin-maternity-hospital-secures-order-to-withdraw-lifesaving-treatment-from-newborn-baby-boy-29920810.html
3. Madden,D. (2002). Medicine, Ethics and Law in Ireland. Dublin: Bloomsbury Professional
4. Nuffield Council on Bioethics (Nuffield) (2006). Critical care decisions in fetal and neonatal medicine: ethical issues. London: Nuffield Council on Bioethics. Retrieved from: www.nuffieldbioethics.org
5. Royal College of Pediatrics and Child Health (RCPCH)(2004). Withholding or Withdrawing Life Sustaining Treatment in Children: a Framework for Practice. 2nd ed. London: 2004. Retrieved from: http://www.gmc-uk.org/Witholding.pdf_40818793.pdf