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Saving vs creating: perceptions of intensive care at different ages and the potential for injustice

Journal of Perinatology volume 33, pages 333–335 (2013)Cite this article

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The American Academy of Pediatrics and others have stated that critical care decisions for neonates, older children and adults should be made similarly.1, 2, 3 Nevertheless, when a newborn is at risk for a certain level of disability, some will deem it acceptable to withhold or withdraw life-sustaining therapy (LST) and allow him to die, whereas an older child with that level of disability may not be considered a candidate for comfort care. If so, there are at least two questions worthy of consideration. First, why might this be so? Second, is it morally justified? This essay provides an analysis of these questions in the setting of the following two cases.

A woman presents to the delivery room in preterm labor at 24 weeks post-menstrual age. The neonatologist meets the parents, and, consistent with policy statements, informs them of the child’s prognosis and their options using all the clinical data that is pertinent to this case.1, 2, 3 They are told that if LST is used, the likelihood of survival is about 50 to 70%. If the baby survives, she will have roughly a 50% chance of not being disabled, a 15 to 25% risk of major disability such as cerebral palsy, blindness, deafness, cognitive impairment and/or developmental delay, and also a significant risk (30 to 40%) of minor disability such as hyperactivity, behavioral problems and learning difficulties. Some babies have more than one of these problems: 5% of babies will have multiple major impairments. The neonatologist also offers the option of providing comfort care only, and states that in that case she would surely die. It is also made clear that if resuscitation is attempted and successful, situations may occur later in which it will be reasonable to consider withdrawing LST.2 After careful explanation of the situation, the risks and the options, the physician makes sure the parents understand and that they have no questions. Catherine’s parents need to decide between LST and comfort care.

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Acknowledgements

We thank Professor Rosalind Ladd for early helpful discussions on the concept of saving vs creating.

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Authors and Affiliations

  1. Department of Pediatrics and Clinical Ethics, University of Montreal, Neonatologist and Clinical Ethicist, Sainte-Justine Hospital, Montreal, QC, USA

    A Janvier

  2. Program for Biomedical Ethics, Yale University School of Medicine, New Haven, CT, USA

    MR Mercurio

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Correspondence to A Janvier.

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Both authors listed on the manuscript have seen and approved the submission of this version of the manuscript and take full responsibility for the manuscript. We do not have any prior publications or submissions with overlapping information (this is an opinion article). Both authors wrote a part of the first draft of the article and are the only ones who contributed to this article. We did not accept an honorarium, grant or other form of payment to produce the manuscript. The authors declare no conflict of interest.

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Janvier, A., Mercurio, M. Saving vs creating: perceptions of intensive care at different ages and the potential for injustice. J Perinatol 33, 333–335 (2013). https://doi.org/10.1038/jp.2012.134

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