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- Mark R. Mercurio, MD, MA*
- *Associate Professor, Yale University School of Medicine, Department of Pediatrics; Director, Yale Pediatric Ethics Program, New Haven, Conn.
Author Disclosure
Dr Mercurio has disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Introduction
Most physician effort and energy in neonatology is extended in an effort to preserve life. Nevertheless, circumstances sometimes arise wherein the best course may be to withhold or withdraw a certain treatment, based on poor prognosis. Such circumstances might include extreme prematurity, severe congenital anomaly, imminent death regardless of treatment, or evidence of profound neurologic injury. Treatments that might be withheld or withdrawn include resuscitation, life-sustaining medical treatment such as mechanical ventilation or artificial nutrition and hydration, and surgical procedures. What follows is intended as a guide to those considering such decisions, based, in part, on policy statements from the American Academy of Pediatrics (AAP).
Withdrawing Versus Withholding
There may be important psychological differences between withdrawing a treatment in progress and withholding it (ie, declining to initiate the specific therapy). Some individuals (staff or family) might have more difficulty stopping a therapy once it has begun. Physicians considering withdrawal of a therapy should be cognizant of this concern but should not mistake it for a sound ethical distinction. The AAP Committee on Bioethics has stated that most philosophical and legal commentators find no important ethical or legal distinction between withdrawing and withholding; (1) that is, if it is ethically acceptable to withhold a given treatment from a given newborn, generally it is acceptable to withdraw it.
Patient's Best Interest and Parental Authority
The determination of when it is ethically acceptable to withdraw or withhold any treatment in the case of a newborn generally is based on the patient's best interest standard and on recognition of parental authority. The patient's best interest standard essentially states that the decision should be made by weighing the anticipated benefits and burdens (to the patient) of …
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