Nuffield Council On Bio-Ethics
On 16th November 2006 the Nuffield Council on Bio-Ethics published a report on the ethical, social, legal and economic issues involved in critical care decisions in premature babies. The role of the Nuffield Council is to examine ethical issues raised by new developments in biology and medicine. The report that it produced recommends that babies born prior to 22 weeks gestation should not receive medical assistance.
There is no discretion in this regard. This is a blanket decision. The recommendations, however, state that babies born between 22 and 23 weeks can be treated following a review with the parents if they so request. The parents’ wishes should be taken into account and a decision should be reached based upon what is in the child’s best interests. Babies born at 25 weeks or later should receive intensive care treatment unless they have an abnormality which means they are unlikely to survive.
The recommendations, therefore, mean that children who are born alive at less than 22 weeks gestation will not have a birth certificate and will be classed as pre-viable and incapable of sustaining life. To some parents it may be unsatisfactory to treat their child as if he or she never existed. Some people may see it as a deception to say that the fetus was born dead when it was, in fact, born alive, was breathing and moving its limbs.
There are approximately 300 children born every year under 22 weeks gestation. There are no statistics on how many of these children survive. At 22 weeks on average two children a year survive. At 23 weeks this increases to 17% and after 25 weeks 44% survive. The Royal College of Obstetricians and Gynaecologists (RCOG) recommended to the Nuffield Council prior to publication of the report that active euthanasia should be allowed to spare parents the emotional and financial burden of bringing up seriously disabled children. This raises such questions as whether it is right to keep children alive when they are so disabled and whether there is actually a difference between aborting a handicapped fetus and killing a newborn child who is born prior to 22 weeks?
The report is not as radical as the recommendations of the RCOG. They were requesting more radical guidance on non resuscitation, withdrawal of treatment decisions, best interests tests and active euthanasia. The aim was to find ways to widen the management options for sick newborn children. The RCOG wanted society to consider mercy killing as is allowed in the Netherlands for incurable conditions such as spina bifida. However, some doctors believe that if intentional killing is allowed, it then becomes a subjective decision as to whose life is worthwhile. Do doctors have the right to decide who should live and who should die? Who is best placed to make this decision? These doctors also believe that medicine is then transformed into a form of social engineering. What impact would this have on disability rights? Are some people really worth less than others?
The report, however, does not recommend active euthanasia. Although there is a blanket decision that children prior to 22 weeks should not be revived and a starting point of non resuscitation with children from 22 to 23 weeks, doctors must consider the parents’ wishes in the case of babies born at 22-23 weeks gestation and reach a decision following appropriate counselling with those parents. The hard facts are that hardly any children survive who are born prior to 22 weeks and this limit has been set by the medical profession based on available data.
We cannot escape the fact, however, that financial factors may have played a part in this decision in that it may be seen that resources are better spent on treating those babies who are more likely to survive. One hopes, however, that in reality the decision is based upon sparing suffering to children unnecessarily.
A final factor to consider in relation to clinical negligence claims is that if a child born under 22 weeks is never classed as alive, no critical incidents will need to be recorded by staff, no investigations will take place within the hospital in relation to treatment, parents will have no recourse for any mistakes that are made and, most importantly, lessons will not be learnt for the future.
Published 26/04/2007.
