Neonatology pp 183-201 | Cite as

Ethical Problems in Neonatal Medicine

  • Otwin LinderkampEmail author
Reference work entry


In perinatal and neonatal medicine, the Hippocratic Oath can be translated into the responsibility of the physicians to act in the “best interests” of the fetus and newborn infant and to avoid harming the fetus and infant and also the mother. This implies that the benefit of treatments should outweigh the harm and risks of the treatment for the patient. The decision-making process is extremely difficult for infants with uncertain prognosis such as extremely preterm infants. The knowledge of long-term outcome is essential for correct and complete antenatal and postnatal counseling of parents and for decision processes in the care of the high risk newborn. Laws and guidelines are necessary and available for care at the limit of viability, but there are different attitudes toward critically ill neonates in different countries, in different centers, and among caregivers in the same center. The decision-making process is articulated in at least three time points: care of mother and fetus before birth, initiation or withholding of resuscitation of the infant after birth, and continuation or withdrawal of neonatal intensive care. Knowledge of newborn and parental rights is the starting point for decisions by physicians from the antenatal until postnatal period.


  1. American Academy of Pediatrics (2007) Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics 119:401–403CrossRefGoogle Scholar
  2. Batton DG, Committee on Fetus and Newborn (2009) Clinical report—Antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 124:422–427CrossRefGoogle Scholar
  3. Bellieni CV, Buonocore G (2009) Flaws in the assessment of the best interests of the newborn. Acta Paediatr 98:613–617CrossRefGoogle Scholar
  4. 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
  5. Boss RD, Hutton N, Sulpar LJ et al (2008) Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics 122:583–589CrossRefGoogle Scholar
  6. Boyle RJ (2004) Ethical issues in the care of the neonate. NeoReviews 5:e471–e476CrossRefGoogle Scholar
  7. Byrne S, Szyld E, Kattwinkel J (2008) The ethics of delivery-room resuscitation. Semin Fetal Neonatal Med 13:440–447CrossRefGoogle Scholar
  8. Carter BS (2004) Comfort care principles for the high-risk newborn. NeoReviews 5:e484–e490CrossRefGoogle Scholar
  9. Chiswick M (2008) Infants at borderline viability: ethical and clinical consideration. Semin Fetal Neonatal Med 13:8–15CrossRefGoogle Scholar
  10. Comitato Nazionale per la Bioetica (2008) I grandi prematuri. Note bioetiche. [EP babies. Bioethical notes].
  11. Cuttini M, Casotto V, Vonderweid U et al (2009) Neonatal end-of-life decisions and bioethical perspectives. Early Hum Dev 85:S21–S25CrossRefGoogle Scholar
  12. Dare T (2009) Parental rights and medical decisions. Pediatr Anesth 19:947–952CrossRefGoogle Scholar
  13. De Leeuw R, Cuttini M, Nadai M et al (2000) Treatment choices for extremely preterm infants: an international perspective. J Pediatr 137:608–616CrossRefGoogle Scholar
  14. 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 8:407–419CrossRefGoogle Scholar
  15. Dunn PM (1990) Life saving intervention in the neonatal period: dilemmas and decisions. Arch Dis Child 65:557–558CrossRefGoogle Scholar
  16. Fanaroff AA (2008) Extremely low birthweight infants-the interplay between outcomes and ethics. Acta Paediatr 97:144–145CrossRefGoogle Scholar
  17. Finer NN, Tarin T, Vaucher YE et al (1999) Intact survival in extremely low birth weight infants after delivery room resuscitation. Pediatrics 104:e40CrossRefGoogle Scholar
  18. 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–F413CrossRefGoogle Scholar
  19. 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–e937CrossRefGoogle Scholar
  20. 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 114:58–64CrossRefGoogle Scholar
  21. Halamek LP (2003) Prenatal consultation at the limits of viability. NeoReviews 4:e153–e156CrossRefGoogle Scholar
  22. Harrison HT (2008) The offer they can’t refuse: parents and perinatal treatment decisions. Semin Fetal Neonatal Med 13:329–334CrossRefGoogle Scholar
  23. Hayward MF, Murphy RO, Lorenz JM (2008) Message framing and perinatal decisions. Pediatrics 122:109–118CrossRefGoogle Scholar
  24. 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 13:325–328CrossRefGoogle Scholar
  25. Hentschel R, Lindner K, Krueger M, Reiter-Theil S (2006) Restriction of ongoing intensive care in neonates: a prospective study. Pediatrics 118:563–569CrossRefGoogle Scholar
  26. Hester DM (2007) Interests and neonates: there is more to the story than we explicitly acknowledge. Theor Med Bioeth 28:357–372CrossRefGoogle Scholar
  27. 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 26:399–406CrossRefGoogle Scholar
  28. Ikeda K, Hayashida S, Hokuto I (2006) International perspectives: recent outcomes of ultrapreterm and extremely low-birth weight infants. Neo Reviews 7:e511–e516Google Scholar
  29. Isaacs D, Kilham H, Gordon A et al (2006) Withdrawal of neonatal mechanical ventilation against the parents’ wishes. J Paediatr Child Health 42:311–315CrossRefGoogle Scholar
  30. Itabashi K, Horiuchi T, Kusuda S et al (2009) Mortality rates for extremely low birth weight infants born in Japan in 2005. Pediatrics 123:445–450CrossRefGoogle Scholar
  31. 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 36:19–22CrossRefGoogle Scholar
  32. Janvier A, Barrington KJ (2005) The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes. J Pediatr 147:579–585CrossRefGoogle Scholar
  33. Janvier A, Bauer KL, Lantos JD (2007) Are newborns morally different from older children? Theor Med Bioeth 28:413–425CrossRefGoogle Scholar
  34. Janvier A, Lantos J, Deschènes M et al (2008a) Caregivers attitudes for very premature infants: what if they knew? Acta Paediatr 97:276–279CrossRefGoogle Scholar
  35. Janvier A, Leblanc I, Barrington KJ (2008b) The best-interest standard is not applied for neonatal resuscitation decisions. Pediatrics 121:963–969CrossRefGoogle Scholar
  36. Janvier A, Leblanc I, Barrington KJ (2008c) Nobody likes premies: the relative value of patients’ life. J Perinatol 28:821–826CrossRefGoogle Scholar
  37. 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 123:1509–1515CrossRefGoogle Scholar
  38. Kipnis K (2007) Harm and uncertainty in newborn intensive care. Theor Med Bioeth 28:393–412CrossRefGoogle Scholar
  39. Kopelman LM (2007) The best interests standard for incompetent or incapacitated persons of all ages. J Law Med Ethics 35:187–196CrossRefGoogle Scholar
  40. 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
  41. Ladd RE, Mercurio MR (2003) Deciding for neonates: whose authority, whose interests? Semin Perinatol 27:488–494CrossRefGoogle Scholar
  42. Lagercrantz H, Changeux JP (2009) The emergence of human consciousness: from fetal to neonatal life. Pediatr Res 65:255–260CrossRefGoogle Scholar
  43. 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 123:1501–1508CrossRefGoogle Scholar
  44. 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–S176CrossRefGoogle Scholar
  45. Levene M (2004) Is intensive care for very immature babies justified? Acta Paediatr 93:149–152CrossRefGoogle Scholar
  46. 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–e638CrossRefGoogle Scholar
  47. Linderkamp O (2012) Survival and outcome of extremely preterm infants in the 90s and early 2000s. Acta Paediatr (in press)Google Scholar
  48. 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
  49. MacDonald H, American Academy of Pediatrics Committee on Fetus and Newborn (2002) Perinatal care at the threshold of viability. Pediatrics 110:1024–1027CrossRefGoogle Scholar
  50. 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
  51. Marsal K, Express Group (2009) Survival of extremely preterm infants after active perinatal care in Sweden. JAMA 301:2225–2233CrossRefGoogle Scholar
  52. 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
  53. 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 109:878–886CrossRefGoogle Scholar
  54. Mercurio MR (2009) The ethics of newborn resuscitation. Semin Perinatol 33:354–363CrossRefGoogle Scholar
  55. 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 96:825–829CrossRefGoogle Scholar
  56. 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 35:13–27Google Scholar
  57. Nishida H, Sakuma I (2009) Limit of viability in Japan: ethical consideration. J Perinat Med 37:457–460CrossRefGoogle Scholar
  58. Nuffield Council on Bioethics (2006) Critical care decisions in fetal and neonatal medicine: ethical issues, London.
  59. Österreichische Gesellschaft für Kinder-und Jugendheilkunde (2005) Erstversorgung von Frühgeborenen an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 7:711–715Google Scholar
  60. Partridge JC, Dickey BJ (2009) Decision-making in neonatal intensive care: interventions on behalf of preterm infants. NeoReviews 10:e270–e278CrossRefGoogle Scholar
  61. Peerzada JM, Schollin J, Håkansson S (2006) Delivery room decision-making for extremely preterm infants in Sweden. Pediatrics 117:1988–1995CrossRefGoogle Scholar
  62. Pignotti MS, Donzelli G (2008a) Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births. Pediatrics 121:e193–e198CrossRefGoogle Scholar
  63. Pohlandt F (2008) Leitlinie zur Frühgeburt an der Grenze der Lebensfähigkeit des Kindes. Monatsschr Kinderheilkd 156:798–802CrossRefGoogle Scholar
  64. 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
  65. Rennie JM, Leigh B (2008) The legal framework for end-of-life decisions in the UK. Semin Fetal Neonatal Med 13:296–300CrossRefGoogle Scholar
  66. Rijken M, Veen S, Walther FJ (2007) Ethics of maintaining preterm infants. Pediatr Child Health 17:58–63CrossRefGoogle Scholar
  67. Saigal S, Stoskopf B, Pinelli J et al (2006) Transition of extremely low birthweight infants from adolescence to young adulthood. Pediatrics 118:1140–1148CrossRefGoogle Scholar
  68. Seri I, Evans J (2008) Limits of viability: definition of the gray zone. J Perinatol Suppl 1:S4–S8CrossRefGoogle Scholar
  69. Singh J, Fanaroff J, Andrews B et al (2007) Resuscitation in the “gray zone” of viability: determining physician preferences and predicting infant outcomes. Pediatrics 120:519–526CrossRefGoogle Scholar
  70. Skupsi DW, McCullough B, Levene M, Chervenak FA (2010) Improving obstetric estimation of outcomes of extremely premature infants: an evolving challenge. J Perinat Med 38:19–22Google Scholar
  71. 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
  72. Tripp J, McGregor D (2006) Withholding and withdrawing of life sustaining treatment in the newborn. Arch Dis Child Fetal Neonatal Ed 91:F67–F71CrossRefGoogle Scholar
  73. Turillazzi E, Fineschi V (2009) How old are you? Newborn gestational age discriminates neonatal resuscitation practices in the Italian debate. BMC Med Ethics 10:19CrossRefGoogle Scholar
  74. Tyson JE, Parikh NA, Langer J et al (2008) Intensive care for extreme prematurity-moving beyond gestational age. N Engl J Med 358:1672–1681CrossRefGoogle Scholar
  75. Verhagen E, Sauer PJJ (2005) The Groningen protocol-euthanasia in severely ill newborns. NEJM 352:959–992CrossRefGoogle Scholar
  76. Verhagen AAE, de Vos M, Dorscheidt JHHM et al (2009a) Conflicts about end-of-life decisions in NICUs in the Netherlands. Pediatrics 124:e112–e119CrossRefGoogle Scholar
  77. Verhagen AAE, Dorscheidt JHHM, Engels B et al (2009b) End-of-life decisions in Dutch neonatal intensive care units. Arch Pediatr Adolesc Med 163:895–901CrossRefGoogle Scholar
  78. Walter FJ (2005) Withholding treatment, withdrawing treatment, and palliative care in the neonatal intensive care unit. Early Hum Dev 81:865–872CrossRefGoogle Scholar
  79. 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–F5CrossRefGoogle Scholar
  80. Wilson-Costello D, Friedman H, Minich N et al (2007) Improved neurodevelopmental outcomes for extremely low birth weight infants in 2000–2002. Pediatrics 119:37–45CrossRefGoogle Scholar
  81. World Health Organization (1993) International classification of diseases (ICD), vol 2, 10th rev edn. World Health Organization, Geneva, SwitzerlandGoogle Scholar
  82. Wyatt JS (1999) Neonatal care: withholding or withdrawal of treatment in the newborn infant. Baillieres Best Pract Res Clin Obstet Gynaecol 13:503–511CrossRefGoogle Scholar
  83. Wyatt J (2007) End-of-life decisions, quality of life and the newborn. Acta Pædiatr 96:790–791CrossRefGoogle Scholar
  84. van Zuuren FJ, van Manen E (2006) Moral dilemmas in neonatology as experienced by health care practitioners: A qualitative approach. Med Health Care Philos 9:339–347CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Neonatology, Department of PediatricsUniversity of HeidelbergHeidelbergGermany

Personalised recommendations