Neonatology has evolved significantly in the past 30 years. Although care of premature infants and their specific disease processes has been studied for the past century, it was the development of the ventilator that truly birthed the field of neonatology. This occurred in the 1960s and was a time of rapid technologic development. These technologies were applied to this new field of neonatology rapidly. We were able to care for children who had previously had no hope of survival. Many of these new technologies had never been used before, and innovation was the hallmark of neonatal care. Although this was essential in saving the lives of literally millions of premature infants during this time period, it also made it difficult to predict outcome or effectiveness of treatment. Issues such as effectiveness of treatment, potential risk to the patient, or quality of life were difficult to determine. However, any treatment was considered better than the hopelessness that these children faced before this era. This “frontier” mentality spurred the application of technology, even in instances where we were unsure of the outcome. This sometimes caused conflict in choosing the best course of action. It was difficult to know when application of technology might be ineffective or might have unintended consequence on the patient’s quality of life.
The present day of neonatology is quite a bit different. We now have a much better idea of quality of life and prognosis. Indeed, the neonatal intensive care unit (NICU) for the most part has become a field of fairly routine but technologically advanced care where the expectation is a minimum of complications and a quality of life and development that are indistinguishable from children who did not require this care. This has allowed us to look more closely at the effectiveness of care and quality of life. We are able to back away from the idea that any care is better than no care and look at our treatment of these patients in a more standard and less pressured framework. As in any field of medicine, this is not to say that there are not ethical dilemmas that occur. There are still significant issues related to the benefits of treatment versus risk and questions about long-term disability, cost of care, and harm to the patient who cannot speak for himself or herself. To answer some of these questions, we would need for framework to discuss the ethical issues involved as well as the medical decision making.
Ethical discussion in medicine has been highly influenced by the ideas of principlism, which have been eloquently described in the foundational textbook of bioethics, Principles of Biomedical Ethics, by Beauchamp and Childress. They describe 4 overriding principles that must be considered when making ethical decisions for patients. These principles are beneficence, nonmaleficence, respect for autonomy, and justice.
Principles that must be ...