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Shedding Light on the Gray Zone:How much discretion should parents have
about life-sustaining treatment for newborn infants with birth asphyxia?
Shedding Light on the Gray Zone:How much discretion should parents have
about life-sustaining treatment for newborn infants with birth asphyxia?
Dominic WilkinsonOxford Nuffield Medical Research FellowJames Martin 21st Century School FellowUniversity of Oxford
Case
Is it permissible to withdraw?
Is it permissible to continue treatment?
University Hospitals Bristol NHS Foundation Trust/PA WireRutherford Seminars in fetal & neonatal medicine (2005) vol. 10 (5) pp. 445-60
Shedding Light on the Gray Zone
Shedding Light on the Gray Zone
Introduction
“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
Life worth living (LWL)
Life not worth living (LNWL)“Intolerable”
Burdens > Benefits
Shedding Light on the Gray Zone
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.”
Shedding Light on the Gray Zone
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Outline
• What is the gray zone?
• Why is there a gray zone?
• Are newborns different?
• Where are the edges of the gray zone?
Shedding Light on the Gray Zone
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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
Shedding Light on the Gray Zone
Different gray zones
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0
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Shedding Light on the Gray Zone
The Threshold view
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Interests
Upper Threshold
Lower Threshold
Shedding Light on the Gray Zone
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Interests
Why parental discretion?
• Overlapping interests
Shedding Light on the Gray Zone
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Interests
Why parental discretion?
• Overlapping interests• Uncertainty
LWLLNWL
Shedding Light on the Gray Zone
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Interests
Why parental discretion?
• Overlapping interests• Uncertainty• Liberalism
Shedding Light on the Gray Zone
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Interests
Why parental discretion?
• Overlapping interests• Uncertainty• Liberalism• Parental interests
?
Shedding Light on the Gray Zone
Are newborns different?
• Uncertainty?• Duration of uncertain prognosis?• Strength of parental rights or interests?• Harm of death?
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Shedding Light on the Gray Zone
Where are the edges of the gray zone?
• Vagueness• Incommensurability
Too hard?
Shedding Light on the Gray Zone
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Where are the edges of the gray zone?
Normative criteria: Upper ThresholdTreatment 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
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Shedding Light on the Gray Zone
Where are the edges of the gray zone?
Normative criteria: Lower ThresholdTreatment 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
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Shedding Light on the Gray Zone
Where are the edges of the gray zone?Practical criteria:
Interests
0Severe Cerebral palsy / Severe Cognitive impairment
Multiple severe impairments - especially combined with ongoing painful illness or medical intervention
Moderate impairments
Shedding Light on the Gray Zone
Advantages of this account
Avoids claim that severe impairments are LNWL
Allows scope for parental discretion
Advantages for care of older children
More consistency in decision-making
Shedding Light on the Gray Zone
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Acknowledgements
Professor Tony HopeProfessor 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?
Shedding Light on the Gray Zone
