Ethical dilemmas in extreme prematurity: recent answers; more questions
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Ethical dilemmas in extreme prematurity
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Ethical Dilemmas In Extreme Prematurity
1. How far can prematurity justify making an
exception to common principles of medical ethics?
While no-one would encourage a systematic, blind,
approach aimed at providing and pursuing intensive care to
all extremely premature infants born alive regardless of
gestational age, there are major ...
European Journal of Obstetrics & Gynecology and
Reproductive Biology 117S (2004) S33–S36
www.elsevier.com/locate/ejogrb
Ethical dilemmas in extreme prematurity:
recent answers; more questions
Umberto Simeonia,*, Mariella Vendemmiaa,
Alina Rizzottia, Marc Gamerreb
a
Department of Neonatology, La Timone University Hospital, 264 rue Saint-Pierre,
13385 Marseille, France
b
Department of Obstetrics and Gynaecology, La Conception University Hospital, Marseille, France
Abstract
Advances in perinatal care allow survival of more extremely premature infants, but the implementation and continuation of intensive care
may itself constitute an ethical dilemma, given the limited chances of intact survival among the patients most at risk. This paper discusses
several key issues raised by the options that are under general consideration with reference to births of infants at the threshold of viability, in
particular: the implications of making a distinction between extreme prematurity and other general medical situations that may involve
decisions on ending support; the concrete nature of the restrictions on therapy in such patients interactions and the need for feedback between
parents, medical staff and society.
# 2004 Elsevier Ireland Ltd. All rights reserved.
Recent years have been marked by major progress in conducted multicentre studies in various countries or from
perinatal and neonatal care, which has allowed a consider- neonatal networks, including cohorts of patients born at
able increase in the survival rates among extremely between 22 and 25 weeks of gestation in the mid-1990s, are
premature infants. However, a high incidence of cerebral now available [1–4]. Panel guidelines therefore commonly
palsy and other major sequelae is still observed in survivors, recommend providing intensive care to patients born at 24 or
while long-term follow-up reveals a high frequency of so- 25 weeks of gestational age or later. Meanwhile, an active
called minor complications that may impinge more than debate is in progress on the subject of preterm births occurring
previously thought on their quality of life. The feeling that between 22 and 24 weeks of gestational age, decision making
limits need to be set for the initiation and the continuation of usually being considered dependent on parental choice or
intensive care in extremely premature infants is shared consent. Fetal indications for caesarean section between 24
widely both among the medical community and among the and 26 weeks of gestation are even more controversial.
public, although it translates differently in different Decision making is generally presented as relying on both
countries and cultures. doctors and parents, but the parental choice on whether their
Traditional questions on limits of viability have usually infant should be resuscitated at birth and/or provided with
been given traditional answers in terms of patient groupings intensive life support is considered determinant [5]. In this
based on gestational age or birth weight, who should or should connection, the objectives of follow-up studies are currently
not receive life support, this decided on the basis of mortality described as aimed at improving information to parents.
rates and of long-term follow-up data. Data from large, well- The aim of the present paper is to discuss several key
ethical issues that are implicit in the current options
* Corresponding author. Tel.: +33 4 91 386 717; fax: +33 4 91 384 899. proposed for premature patients born at the threshold of
E-mail address: umberto.simeoni@ap-hm.fr (U. Simeoni). viability, for their parents and for society.
0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2004.07.016
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