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Dominic Wilkinson. Oxford Nuffield Medical Research Fellow James Martin 21st Century School Fellow University of Oxford. Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia?. Case.
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Dominic Wilkinson Oxford Nuffield Medical Research Fellow James Martin 21st Century School Fellow University of Oxford Shedding Light on the Gray Zone:How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia?
Case Shedding Light on the Gray Zone • Is it permissible to withdraw? • Is it permissible to continue treatment? University Hospitals Bristol NHS Foundation Trust/PA Wire Rutherford Seminars in fetal & neonatal medicine (2005) vol. 10 (5) pp. 445-60
Introduction Shedding Light on the Gray Zone “The treatment of infants should be based on what is perceived to be in their best interest.” Pediatrics 2007;119:403
The Zero line view 0 Interests Shedding Light on the Gray Zone Life worth living (LWL) “Intolerable” Life not worth living (LNWL) Burdens > Benefits
The gray zone Shedding Light on the Gray Zone “The treatment of infants should be based on what is perceived to be in their best interest.” Pediatrics 2007;119:403 “[where] the prognosis is uncertain but likely to be very poor and survival may be associated with a diminished quality of life for the child… parental desires should determine the treatment approach.” ?????
Outline Shedding Light on the Gray Zone • What is the gray zone? • Why is there a gray zone? • Are newborns different? • Where are the edges of the gray zone? ?????
The gray zone Shedding Light on the Gray Zone • Cases or conditions where it would be permissible either to withdraw life-sustaining treatment, or to continue life-sustaining treatment and parental wishes may determine decision
Different gray zones 0 0 0 0 Shedding Light on the Gray Zone
The Threshold view 0 Interests Shedding Light on the Gray Zone Upper Threshold Lower Threshold
Why parental discretion? 0 Interests Shedding Light on the Gray Zone • Overlapping interests
Why parental discretion? 0 Interests Shedding Light on the Gray Zone • Overlapping interests • Uncertainty LNWL LWL
Why parental discretion? 0 Interests Shedding Light on the Gray Zone • Overlapping interests • Uncertainty • Liberalism
Why parental discretion? 0 Interests Shedding Light on the Gray Zone • Overlapping interests • Uncertainty • Liberalism • Parental interests ?
Are newborns different? Shedding Light on the Gray Zone • Uncertainty? • Duration of uncertain prognosis? • Strength of parental rights or interests? • Harm of death? ?????
Where are the edges of the gray zone? Shedding Light on the Gray Zone • Vagueness • Incommensurability • Too hard? ?????
Where are the edges of the gray zone? Shedding Light on the Gray Zone • Normative criteria: Upper Threshold • Treatment withdrawal is permissible for infants with conditions that: • C1. Reduce future wellbeing, either by reducing benefits or by imposing substantial burdens on the child (or both) AND • C2. Are close to the level of a LNWL, AND EITHER • C3. Involve a significant risk of a LNWL OR • C4. Impose a substantial burden of care on others ?????
Where are the edges of the gray zone? Shedding Light on the Gray Zone • Normative criteria: Lower Threshold • Treatment withdrawal is not permissible for infants with conditions that: • C1. Reduce future wellbeing, either by reducing benefits or by imposing substantial burdens on the child (or both) AND • C5. Render it highly likely that the infant will have a LNWL and be harmed by continuing treatment ?????
Where are the edges of the gray zone? Shedding Light on the Gray Zone • Practical criteria: Interests Moderate impairments Severe Cerebral palsy / Severe Cognitive impairment 0 Multiple severe impairments - especially combined with ongoing painful illness or medical intervention
Advantages of this account Shedding Light on the Gray Zone • Avoids claim that severe impairments are LNWL • Allows scope for parental discretion • Advantages for care of older children • More consistency in decision-making ?????
Acknowledgements Shedding Light on the Gray Zone Professor Tony Hope Professor Julian Savulescu • Nuffield Dominions Trust (Oxford Nuffield Medical Fellowship) • Eric Burnard Fellowship • RACP Astra-Zeneca Medical Fellowship • Royal Children’s Hospital Traveling Scholarship Questions, comments suggestions? dominic.wilkinson@ethox.ox.ac.uk