Abstract
Critical decision-making in neonatology and other areas of pediatrics often carries with it a complex and difficult ethical component. For any treatment under consideration, the impermissible–permissible–obligatory (I–P–O) spectrum provides a useful framework for determining how to proceed. Any proposed treatment can be located along this spectrum, and identified as either ethically impermissible, permissible, or obligatory. Treatments determined to be ethically impermissible should not be made available by physicians. Those deemed ethically permissible should be explained to parents, commonly with a specific recommendation. Informed parents should then be free to choose from among permissible options. Potential treatments deemed ethically obligatory should be provided to the patient, even in the face of parental objection. The fundamental ethical work in neonatology and pediatrics is determining where on the I–P–O spectrum a treatment under consideration should be located. This should be determined by the prognosis for the patient with and without the treatment, the feasibility of providing the treatment, and consideration of all relevant rights and obligations. Location on the line is dynamic, and clinicians should be open to movement of a given treatment along the spectrum as new information, particularly regarding effectiveness, toxicity, and/or alternatives, becomes available. This framework provides a structure for ethical conversation and decision-making related to a specific patient, as well as in the formation of institutional and national guidelines.
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Funding Information
CLC is supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health under award R01HD094794 (CC PI). MRM is supported by a grant from National Institutes of Health 5R25TW007700.
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MRM participated in the development of the concepts and framework, wrote the first draft of the manuscript, and participated in the revision of the manuscript. CLC participated in the development of the concepts and framework, and participated in the revision of the manuscript.
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CLC has no conflicts of interest to disclose. MRM receives royalty payments as a contributor to the online publication Up-To-Date.
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Mercurio, M.R., Cummings, C.L. Critical decision-making in neonatology and pediatrics: the I–P–O framework. J Perinatol 41, 173–178 (2021). https://doi.org/10.1038/s41372-020-00841-6
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DOI: https://doi.org/10.1038/s41372-020-00841-6
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