Neonatology pp 102-113 | Cite as

Ethical Problems

  • Otwin Linderkamp


“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” The Hippocratic Oath expressed beneficence and non-maleficence as basic principles of medical ethics more than 2000 years ago. Beneficence in perinatal and neonatal medicine refers to the responsibility of the physicians to act in the “best interests” of the fetus and newborn infant. Non-maleficence relates to the avoidance of harm to the fetus and infant, but also to the mother. This implies that the benefit of treatments should outweigh the harm and risks of the treatment for the patient.


Down Syndrome Newborn Infant Good Interest Neurodevelopmental Disability Sick Infant 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Bellieni CV, Buonocore G (2009) Flaws in the assessment of the best interests of the newborn. Acta Paediatr 98:613–617PubMedCrossRefGoogle Scholar
  2. 2.
    Janvier A, Lantos J, Deschènes M et al (2008) Caregivers attitudes for very premature infants: what if they knew? Acta Paediatr 97:276–279PubMedCrossRefGoogle Scholar
  3. 3.
    Levene M (2004) Is intensive care for very immature babies justified? Acta Paediatr 93:149–152Google Scholar
  4. 4.
    Skupsi DW, McCullough B, Levene M, Chervenak FA (2010) Improving obstetric estimation of outcomes of extremely premature infants: an evolving challenge. J Perinat Med 38:19–22CrossRefGoogle Scholar
  5. 5.
    Linderkamp O (2012) Survival and outcome of extremely preterm infants in the 90s and early 2000s. Acta Paediatr (in press)Google Scholar
  6. 6.
    Nishida H, Sakuma I (2009) Limit of viability in Japan: ethical consideration. J Perinat Med 37:457–460PubMedCrossRefGoogle Scholar
  7. 7.
    Kusuda S, Fujimura M, Sakuma I et al (2006) Morbidity and mortality of infants with very low birth weight in Japan. center variation. Pediatrics 118:e1131–e1139CrossRefGoogle Scholar
  8. 8.
    Itabashi K, Horiuchi T, Kusuda S et al (2009) Mortality rates for extremely low birth weight infants born in Japan in 2005. Pediatrics 123:445–450PubMedCrossRefGoogle Scholar
  9. 9.
    Marsal K, Express Group (2009) Survival of extremely preterm infants after active perinatal care in Sweden. JAMA 301:2225–2233PubMedCrossRefGoogle Scholar
  10. 10.
    Moser K, Macfarlane A, Chow YH et al (2007) Introducing new data on gestation-specific infant mortality among babies born in 2005 in England and Wales. Health Stat Q 35:13–27PubMedGoogle Scholar
  11. 11.
    Markestad T, Kaaresen PI, Ronnestad A et al (2005) Early death, morbidity, and need of treatment among extremely premature infants, Pediatrics 15:1289–1298CrossRefGoogle Scholar
  12. 12.
    Ikeda K, Hayashida S, Hokuto I (2006) International perspectives: recent outcomes of ultrapreterm and extremely low-birth weight infants. NeoReviews 7:e511–e516CrossRefGoogle Scholar
  13. 13.
    Iijima S, Arai H, Ozawa Y et al (2009) Clinical patterns in extremely preterm (22 to 24 weeks of gestation) infants in relation to survival time and prognosis. Am J Perinatol 26:399–406PubMedCrossRefGoogle Scholar
  14. 14.
    Wilson-Costello D, Friedman H, Minich N et al (2007) Improved neurodevelopmental outcomes for extremely low birth weight infants in 2000–2002. Pediatrics 119:37–45PubMedCrossRefGoogle Scholar
  15. 15.
    Hakansson S, Farooqi A, Holmgren PA et al (2004) Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies. Pediatrics 114:58–64PubMedCrossRefGoogle Scholar
  16. 16.
    Singh J, Fanaroff J, Andrews B et al (2007) Resuscitation in the “gray zone” of viability: determining physician preferences and predicting infant outcomes. Pediatrics 120:519–526PubMedCrossRefGoogle Scholar
  17. 17.
    Finer NN, Tarin T, Vaucher YE et al (1999) Intact survival in extremely low birth weight infants after delivery room resuscitation. Pediatrics 104:e40PubMedCrossRefGoogle Scholar
  18. 18.
    Jankov RP, Asztalos EV, Scidmore MB (2000) Favourable neurological outcomes following delivery room cardiopulmonary resuscitation of infants ≤750 g at birth. J Paediatr Child Health 36:19–22PubMedCrossRefGoogle Scholar
  19. 19.
    Walter FJ (2005) Withholding treatment, withdrawing treatment, and palliative care in the neonatal intensive care unit. Early Hum Dev 81:865–872CrossRefGoogle Scholar
  20. 20.
    Seri I, Evans J (2008) Limits of viability: definition of the gray zone. J Perinatol Suppl 1:S4–8CrossRefGoogle Scholar
  21. 21.
    Lagercrantz H, Changeux JP (2009) The emergence of human consciousness: from fetal to neonatal life. Pediatr Res 65:255–260PubMedCrossRefGoogle Scholar
  22. 22.
    Comitato Nazionale per la Bioetica (2008) I grandi prematuri. Note bioetiche. [EP babies. Bioethical notes]. Google Scholar
  23. 23.
    World Health Organization (1993) International Classification of Diseases (ICD), 10th revision. Vol 2. World Health Organization, Geneva, SwitzerlandGoogle Scholar
  24. 24.
    Partridge JC, Dickey BJ (2009) Decision-making in neonatal intensive care: interventions on behalf of preterm infants. NeoReviews 10:e270–e278CrossRefGoogle Scholar
  25. 25.
    MacDonald H, American Academy of Pediatrics Committee on Fetus and Newborn (2002) Perinatal care at the threshold of viability. Pediatrics 110:1024–1027Google Scholar
  26. 26.
    American Academy of Pediatrics (2007) Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics 119:401–403CrossRefGoogle Scholar
  27. 27.
    Pignotti MS, Donzelli G (2008) Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births. Pediatrics 121:e193–e198PubMedCrossRefGoogle Scholar
  28. 28.
    Turillazzi E, Fineschi V (2009) How old are you? Newborn gestational age discriminates neonatal resuscitation practices in the Italiandebate. BMC Med Ethics 10:19PubMedCrossRefGoogle Scholar
  29. 29.
    MacDonald H, American Academy of Pediatrics Committee on Fetus and Newborn (2002) Perinatal care at the threshold of viability. Pediatrics 110:1024–1027PubMedCrossRefGoogle Scholar
  30. 30.
    Pignotti MS, Donzelli G (2008) Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births. Pediatrics 121:e193–198PubMedCrossRefGoogle Scholar
  31. 31.
    Lui K, Bajuk B, Foster K et al (2006) Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop. Med J Aust 185:495–500PubMedGoogle Scholar
  32. 32.
    Nuffield Council on Bioethics (2006) Critical care decisions in fetal and neonatal medicine: ethical issues. London. Google Scholar
  33. 33.
    Wilkinson AR, Ahluwalia J, Cole A et al (2009) Management of babies born extremely preterm at less than 25 weeks of gestation: a framework for clinical practices at the time of birth. Arch Dis Child Fetal Neonatal Ed 94:F2–5PubMedCrossRefGoogle Scholar
  34. 34.
    Peerzada JM, Schollin J, Håkansson S (2006) Delivery room decision-making for extremely preterm infants in Sweden. Pediatrics 117:1988–1995PubMedCrossRefGoogle Scholar
  35. 35.
    Miljeteig I, Markestad T, Norheim OF (2007) Physicians’ use of guidelines and attitudes to withholding and withdrawing treatment for extremely premature neonates in Norway. Acta Paediatr 96:825–829PubMedCrossRefGoogle Scholar
  36. 36.
    Rijken M, Veen S, Walther FJ (2007) Ethics of maintaining preterm infants. Pediatr Child Health 17:58–63CrossRefGoogle Scholar
  37. 37.
    Pohlandt F (2008) Leitlinie zur Frühgeburt an der Grenze der Lebensfähigkeit des Kindes. Monatsschr Kinderheilkd 156:798–802CrossRefGoogle Scholar
  38. 38.
    Österreichische Gesellschaft für Kinder-und Jugendheilkunde (2005) Erstversorgung von Frühgeborenen an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 7:711–715Google Scholar
  39. 39.
    Dehan M, Gold F, Grassin M et al (2001) Dilemmes éthiques de la période périnatale: recommendations pour les decisions de fin de vie. Arch Pediatr 8:407–419PubMedCrossRefGoogle Scholar
  40. 40.
    Fischer N, Steurer MA, Adams M et al (2009) Survival rates of extremely preterm infants (gestational age <26 weeks) in Switzerland: impact of the Swiss guidelines for the care of infants born at the limit of viability. Arch Dis Child Fetal Neonatal Ed 94:F407–F413PubMedCrossRefGoogle Scholar
  41. 41.
    Fanaroff AA (2008) Extremely low birthweight infants-the interplay between outcomes and ethics. Acta Pædiatr 97:144–145PubMedCrossRefGoogle Scholar
  42. 42.
    Tyson JE, Parikh NA, Langer J et al (2008) Intensive care for extreme prematurity-moving beyond gestational age. N Engl J Med 358:1672–1681PubMedCrossRefGoogle Scholar
  43. 43.
    Hester DM (2007) Interests and neonates: there is more to the story than we explicitly acknowledge. Theor Med Bioeth 28:357–372PubMedCrossRefGoogle Scholar
  44. 44.
    Kopelman LM (2007) The best interests standard for incompetent or incapacitated persons of all ages. J Law Med Ethics 35:187–196PubMedCrossRefGoogle Scholar
  45. 45.
    Chiswick M (2008) Infants at borderline viability: ethical and clinical consideration. Semin Fetal Neonatal Med 13:8–15PubMedCrossRefGoogle Scholar
  46. 46.
    Kipnis K (2007) Harm and uncertainty in newborn intensive care. Theor Med Bioeth 28:393–412Google Scholar
  47. 47.
    Meadow W, Frain L, Ren Y et al (2002) Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent. Pediatrics 109:878–886PubMedCrossRefGoogle Scholar
  48. 48.
    Saigal S, Stoskopf B, Pinelli J et al (2006) Transition of extremely low birthweight infants from adolescence to young adulthood. Pediatrics 118:1140–1148PubMedCrossRefGoogle Scholar
  49. 49.
    Wyatt J (2007) End-of-life decisions, quality of life and the newborn Acta Pædiatr 96:790–791PubMedCrossRefGoogle Scholar
  50. 50.
    Bilgen H, Topuzoglu A, Kuscu K et al (2007) End-of-life decisions in the newborn period: attitudes and practices of doctors and nurses. Turk J Pediatr 51:248–256Google Scholar
  51. 51.
    Cuttini M, Casotto V, Vonderweid U et al (2009) Neonatal end-of-life decisions and bioethical perspectives. Early Hum Dev 85:S21–25PubMedCrossRefGoogle Scholar
  52. 52.
    De Leeuw R, Cuttini M, Nadai M et al (2000) Treatment choices for extremely preterm infants: an international perspective. J Pediatr 137:608–616PubMedCrossRefGoogle Scholar
  53. 53.
    Lavin JP, Kantak A, Ohlinger J et al (2006) Attitudes of obstetric and pediatric health care providers toward resuscitation of infants who are born at the margins of viability. Pediatrics 118:S169–176PubMedCrossRefGoogle Scholar
  54. 54.
    van Zuuren FJ, van Manen E (2006) Moral dilemmas in neonatology as experienced by health care practitioners: A qualitative approach. Med Health Care Philos 9:339–347PubMedCrossRefGoogle Scholar
  55. 55.
    Lam HS, Wong SPS, Liu FYB et al (2009) Attitudes toward neonatal intensive care treatment of preterm infants with a high risk of developing long-term disabilities. Pediatrics 123:1501–1508PubMedCrossRefGoogle Scholar
  56. 56.
    Janvier A, Leblanc I, Barrington KJ (2008) The best-interest standard is not applied for neonatal resuscitation decisions. Pediatrics 121:963–969PubMedCrossRefGoogle Scholar
  57. 57.
    Janvier A, Bauer KL, Lantos JD (2007) Are newborns morally different from older children? Theor Med Bioeth 28:413–425PubMedCrossRefGoogle Scholar
  58. 58.
    Janvier A, Leblanc I, Barrington KJ (2008) Nobody likes premies: the relative value of patients’ life. J Perinatol 28:821–826PubMedCrossRefGoogle Scholar
  59. 59.
    Mercurio MR (2009) The ethics of newborn resuscitation. Semin Perinatol 33:354–363PubMedCrossRefGoogle Scholar
  60. 60.
    Dare T (2009) Parental rights and medical decisions. Pediatr Anesth 19:947–952CrossRefGoogle Scholar
  61. 61.
    Harrison HT (2008) The offer they can’t refuse: parents and perinatal treatment decisions. Semin Fetal Neonatal Med 13:329–334PubMedCrossRefGoogle Scholar
  62. 62.
    Halamek LP (2003) Prenatal consultation at the limits of viability. NeoReviews 4:e153–156CrossRefGoogle Scholar
  63. 63.
    Batton DG, Committee on Fetus and Newborn (2009) Clinical report—Antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 124:422–427PubMedCrossRefGoogle Scholar
  64. 64.
    Ladd RE, Mercurio MR (2003) Deciding for neonates: whose authority, whose interests? Semin Perinatol 27:488–494PubMedCrossRefGoogle Scholar
  65. 65.
    Griswold KJ, Fanaroff JM (2010) An evidence-based overview of prenatal consultation with a focus on infants born at the limits of viability. Pediatrics 125:e931–e937PubMedCrossRefGoogle Scholar
  66. 66.
    Hayward MF, Murphy RO, Lorenz JM (2008) Message framing and perinatal decisions. Pediatrics 122:109–118CrossRefGoogle Scholar
  67. 67.
    Leversen KT, Sommerfelt K, Rønnestad A et al (2011) Prediction of neurodevelopmental and sensory outcome at 5 years in Norwegian children born extremely preterm. Pediatrics 127:e630–e638PubMedCrossRefGoogle Scholar
  68. 68.
    Martinez AM, Partridge JC, Yu V et al (2006) Physician counselling practices and decision-making for extremely preterm infants in the Pacific Rim. J Paediatr Child Health 41:209–214CrossRefGoogle Scholar
  69. 69.
    Kaempf JW, Tomlinson MW, Campbell B et al (2009) Counseling pregnant women who may deliver extremely premature infants: medical care guidelines, family choices, and neonatal outcomes. Pediatrics 123:1509–1515PubMedCrossRefGoogle Scholar
  70. 70.
    Boss RD, Hutton N, Sulpar LJ et al (2008) Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics 122:583–589PubMedCrossRefGoogle Scholar
  71. 71.
    Dunn PM (1990) Life saving intervention in the neonatal period: dilemmas and decisions. Arch Dis Child 65:557–558PubMedCrossRefGoogle Scholar
  72. 72.
    Henley A, Judith Schot J (2008) The death of a baby before, during or shortly after birth: Good practice from the parents’ perspective. Semin Fetal Neonatal Med 13:325–328PubMedCrossRefGoogle Scholar
  73. 73.
    Tripp J, McGregor D (2006) Withholding and withdrawing of life sustaining treatment in the newborn. Arch Dis Child Fetal Neonatal Ed 91:F67–F71PubMedCrossRefGoogle Scholar
  74. 74.
    Verhagen AAE, de Vos M, Dorscheidt JHHM et al (2009) Conflicts about end-of-life decisions in NICUs in the Netherlands. Pediatrics 124:e112–e119PubMedCrossRefGoogle Scholar
  75. 75.
    Isaacs D, Kilham H, Gordon A et al (2006) Withdrawal of neonatal mechanical ventilation against the parents’ wishes. J Paediatr Child Health 42:311–315PubMedCrossRefGoogle Scholar
  76. 76.
    Hentschel R, Lindner K, Krueger M, Reiter-Theil S (2006) Restriction of ongoing intensive care in neonates: a prospective study. Pediatrics 118:563–569PubMedCrossRefGoogle Scholar
  77. 77.
    Verhagen AAE, Dorscheidt JHHM, Engels B et al (2009) End-of-life decisions in Dutch neonatal intensive care units. Arch Pediatr Adolesc Med 163:895–901PubMedCrossRefGoogle Scholar
  78. 78.
    Boyle RJ (2004) Ethical issues in the care of the neonate. NeoReviews 5:e471–e476CrossRefGoogle Scholar
  79. 79.
    Wyatt JS (1999) Neonatal care: withholding or withdrawal of treatment in the newborn infant. Baillieres Best Pract Res Clin Obstet Gynaecol 13:503–511PubMedCrossRefGoogle Scholar
  80. 80.
    Janvier A, Barrington KJ (2005) The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes. J Pediatr 147:579–585PubMedCrossRefGoogle Scholar
  81. 81.
    The International Liaison Committee on Resuscitation (ILCOR) (2006) Consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics 117:e978–e988CrossRefGoogle Scholar
  82. 82.
    Carter BS (2004) Comfort care principles for the high-risk newborn. NeoReviews 5:e484–e490CrossRefGoogle Scholar
  83. 83.
    Provost V, Deliens L, Cools F et al (2004) A classification of end-of-life decisions in neonates and infants. Acta Paediatr 93:301–305CrossRefGoogle Scholar
  84. 84.
    Verhagen E, Sauer PJJ (2005) The Groningen protocol-euthanasia in severely ill newborns. NEJM 352:959–992PubMedCrossRefGoogle Scholar
  85. 85.
    Byrne S, Szyld E, Kattwinkel J (2008) The ethics of delivery-room resuscitation. Semin Fetal Neonatal Med 13:440–447PubMedCrossRefGoogle Scholar
  86. 86.
    Rennie JM, Leigh B (2008) The legal framework for end-of-life decisions in the UK. Semin Fetal Neonatal Med 13:296–300PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2012

Authors and Affiliations

  • Otwin Linderkamp
    • 1
  1. 1.Division of Neonatology, Department of PediatricsUniversity of HeidelbergHeidelbergGermany

Personalised recommendations