Tag: neonates

Bioethics News

Neonates Resuscitation with serious medical disorders. Remarkable medical and ethical issue

A bioethics problem that often presents is knowing who should make the decision regarding resuscitation of neonates with serious medical disorders and whether this decision should correspond to physicians. In relation to this, an article published in the Journal of Medical Ethics has addressed this issue (Neonates Resuscitation), after sending a survey to 3000 members of the American Academy of Pediatrics Section of Perinatal Medicine. A total of 490 neonatologists (16%) responded. The majority (76%) of the physicians that responded stated that a unilateral decision of the physician not to resuscitate should be permissible only in cases in which survival was virtually impossible. A minority (25%) responded that it should be carried out, even if that decision meant the poor neurological development of the neonate. In our opinion, these decisions could have important implications for ethical and clinical practice.

La entrada Neonates Resuscitation with serious medical disorders. Remarkable medical and ethical issue aparece primero en Bioethics Observatory.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Human Milk Banking in Guatemala City: All for All

Martha Paynter compares human milk banking practices in Guatemala City and Atlantic Canada.

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Last month, non-profit human milk banking staff and researchers from across the continent met in Dallas for the Human Milk Banking of North America 2017 Symposium to share best practices and new developments. The use of human donor milk is growing and non-profit banks must compete with for-profit enterprises and private milk markets. Human donor milk health and safety standards in North America continue to evolve in response to scientific evidence, epidemiological developments such as Zika, and funding changes including the recent Medicaid coverage for banked milk in New York State. While we adapt processes and goals for milk banking in North America, it is worth examining alternative models of milk bank operations.

In Atlantic Canada, for example, three level-3 Neonatal Intensive Care Units (NICU) provide human donor milk to infants under 1500 grams who are unable to receive sufficient milk from their own mothers. The milk is purchased at approximately $5/ounce, including shipping, from the Northern Star Mothers Milk Bank in Calgary. Northern Star is a private, community-based non-profit business. Milk is collected from healthy volunteer lactating women across Canada who meet donor criteria. Donors may take some medications, but not pharmaceuticals or herbs to promote lactation. Donors ship the frozen milk by courier to Northern Star, where it is pasteurized and distributed to NICUs, inpatients and outpatients across the country according to need and availability. Since opening in 2012, Northern Star has distributed over 500,000 ounces of milk.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

In the Journals – April 2017 by Danya Glabau

Critical Public Health

On difference and doubt as tools for critical engagement with public health

Catherine M. Will

This paper argues that critical public health should reengage with public health as practice by drawing on versions of Science and Technology Studies (STS) that ‘de-centre the human’ and by seeking alternative forms of critique to work inspired by Foucault. Based on close reading of work by Annemarie Mol, John Law, Vicky Singleton and others, I demonstrate that these authors pursue a conversation with Foucault but suggest new approaches to studying contemporary public health work in different settings. Proposing that we ‘doubt’ both the unity of public health and its effects, I argue that this version of STS opens up a space to recognise multiplicity; to avoid idealising what is being criticised; and to celebrate or care for public health practices as part of critique. Finally I oppose the view that considering technologies, materials and microbes leads to micro-level analysis or political neutrality, and suggest that it allows us to reframe studies of public health to account for inequalities and to draw attention to weak or retreating states, active markets and the entangled relations of humans and non-humans across the world.

 

Biopolitical precarity in the permeable body: the social lives of people, viruses and their medicines

Elizabeth Mills

This article is based on multi-sited ethnography that traced a dynamic network of actors (activists, policy-makers, health care systems, pharmaceutical companies) and actants (viruses and medicines) that shaped South African women’s access to, and embodiment of, antiretroviral therapies (ARVs).

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Dominic Wilkinson, Death or Disability: The Carmentis Machine and Decision-Making for Critically Ill Children, Oxford University Press, 2013

Dominic Wilkinson, a neonatal physician and medical ethicist, has written a searching, moving, and philosophically sophisticated book about the ethics of life and death decision making in the neonatal intensive care unit. Although I will devote much of this review to criticism, I want to say at the outset that Death or Disability represents interdisciplinary work at its very best. Wilkinson’s exposition is both rich in detail and uncompromising in its ethical analysis. He spares the reader none of the clinical, psychological, and moral complexities and uncertainties of the decisions made daily in the neonatal intensive care unit (NICU).

I especially recommend this book to moral philosophers and practical ethicists worried that their debates on issues like time-relative interests and non-identity are ingrown and academic. Wilkinson explains the relevance of these and other seemingly arcane issues to the real, wrenching decisions that parents, physicians, and the larger society must make about the treatment of newborns at risk of very severe impairment.

After briefly outlining the structure of the book and some of its complex arguments, I will focus on three of the few areas where Wilkinson’s thorough, painstaking analysis strikes me as incomplete: the role of impersonal considerations in decisions about continuing or ending the lives of impaired neonates; the implications of the time-relative interest account Wilkinson adopts for balancing potentially conflicting interests in the neonate’s survival; and the role of physicians in helping to make neonatal treatment decisions under the threshold framework Wilkinson proposes.

The book begins with two prologues about imagined visits to learn the fate of a sickly neonate: one to the Roman Temple of Carmentis in 30 AD, the other to The Carmentis Machine in 2030.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Giving Newborns Medicine Is a Dangerous Guessing Game. Can We Make It Safer?

January 5, 2017

(STAT News) – Pharma companies are afraid to test drugs on babies because they’re so vulnerable, and because the risk of liability is so high. Parents and doctors say they’re wary of enlisting newborns as “guinea pigs” in clinical trials. The result: An estimated 90 percent of medications administered to newborns are not approved by the Food and Drug Administration for use in children so young. That means neonates — premature and full-term infants less than 28 days old — are routinely treated with drugs that are not adequately tested for safety, dosing, or effectiveness.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Infant Topography: Baby Body Mapping in Maphisa, Zimbabwe by Min’enhle Ncube

Nomsa, her sixteen month old son Nathi and I met early one morning at the entrance to the open cast mine in Mafuyana, Southern Matabeleland, Zimbabwe. Nathi safely secured on her back, a shovel in one hand and a plastic bag with bread and water in the other, Nomsa hurried me along: “We must walk quickly, the earlier I start working, the earlier I can knock-off. This little one gets irritated when hungry, plus he has a bit of flu in this cold”. We walked briskly through the maze of thorny acacia and mopane bush for about thirty minutes—some three kilometres. Despite the absence of trails, Nomsa navigated the landscape well. We passed several abandoned deep vertical shaft gold mines before we arrived at the open cast mine pits where she worked with two other women, extracting ore. She sat Nathi down in the shade and began work, digging the rocky ore from one side, piling it on the other. Intermittently, she breastfed Nathi, usually when he became irritable. The women worked hard, pausing only for tea until mid-afternoon, when they packed up and we returned to Maphisa, the new development zone where they lived.

Nomsa lived in a single room shared with her husband and two children. The room was dim; there were no curtains or lights. The small room was crammed with a double bed, a chipped wooden wardrobe, and a kitchen unit. The floor was cemented concrete, uneven, unrefined and dusty. Nomsa’s room was part of a larger housing unit that comprising a toilet and kitchen (without either water or electricity) and a bedroom on either side.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

When Doctors and Parents Disagree Ethics, Paediatrics and the Zone of Parental Discretion

A new book explores ethical decision­making when clinicians and parents disagree about medical  treatment for a child.  

When Doctors and Parents Disagree Ethics, Paediatrics and the Zone of Parental Discretion develops and explores a concept called the zone of parental discretion: an ethical tool that aims to balance children’s wellbeing and parents’ rights to make medical decisions for their children. 

Written by experienced clinical ethicists and paediatric clinicians, this book offers ethical analysis and practical guidance based on real­life clinical cases. It aims to assist doctors, nurses, allied health professionals and clinical ethics staff to deal with these ethically challenging situations.

In paediatrics, clinicians and parents sometimes disagree about the appropriate medical treatment for a child. Parents can prefer an option that differs from the clinician’s recommendation. When should the parents’ decision about their child’s medical treatment be overridden?


Part I – An ethical tool: the zone of parental discretion

1.  The zone of parental discretion

2.  Within the ZPD: focusing on harm and children’s interests

Part II – Roles of doctors and parents in decision­making

3. So, do we really need doctors anyway? Information, expertise and the changing dynamic between doctors and families

4. Who should decide for critically ill neonates and how? The grey zone in neonatal treatment decisions

5. Parental rights: who has them and what are their limits?

Part III – Clinicians encountering parental refusals

6. The rehabilitation context: the ZPD and ongoing care questions 

7. When a parental refusal of treatment is only distantly or unpredictably life ­threatening to the child

8. Parental discretion and medical tests for children

Part IV – Clinicians encountering parental requests for treatment

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The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Technologies of Care: Administering Donated Breast Milk in a South African Neonatal Intensive Care Unit by Miriam Waltz

This is the third installment of the series from the University of Cape Town’s First Thousand Day Research Group. My research traces out the pathways of donated milk from donor to recipient in a state neonatal unit in South Africa (Waltz 2015), to show how care and technologies are interwoven in complex and sometimes surprising ways.

Breastfeeding is widely seen as the best infant feeding option for mother and baby. The dominant discourse in both the public and the medical realm presents breastfeeding as a natural behaviour, best for babies, best for mums. In a recent series, The Lancet claims that increasing breastfeeding worldwide could prevent over 800,000 child deaths every year (Victora et al. 2016). This position is reflected in state policy and official declarations of the World Health Organisation (WHO) and UNICEF. In South Africa, after a decade of promoting the use of formula milk to offset possible vertical (mother to child) HIV transmission, the state re-committed to facilitating breastfeeding in the Tshwane declaration of August 2011 (see also Doherty et al. 2010 for the revised WHO guidelines on breastfeeding). Breast milk is even more important in the case of premature or low birth weight babies, who are highly susceptible to necrotising enterocolitis, (a serious gastrointestinal condition) if fed on formula milk (Neu and Walker 2011). Here, breast milk is critical in securing life; ‘breast is best’ (Murphy 1999). Where the birth mother’s breast milk is not available, donated breast milk is the best alternative.

My research on the milk’s trajectories was wide-ranging. I interviewed donor mothers; members of milk banks associated with the collection, testing, packaging and distribution of donated milk; hospital staff responsible for its prescription and distribution; and mothers whose infants were receiving donated milk.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

OB Potpourri

This month’s issue of the medical journal Obstetrics & Gynecology (O&G) has a review of the four best ethics articles that appeared in their journal in the last year. Here are my comments (in italics) on their review (in quotes).

Article title: “Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.” O&G‘s bottom line: “Opioid abuse is a chronic medical illness, not a moral failing. Obstetricians should advocate for pregnant women’s access to opioid maintenance therapy and social services that support healthy outcomes for these women and their fetuses.” Some will quibble about whether the slavery that is opioid addiction should be defined as a chronic medical illness (and remember that some opioid addiction comes courtesy of us physicians who misprescribe opioid medications). However, whether you believe that these women are unable to stop their substance abuse (illness model) or somehow unwilling (moral failure model), from a medical standpoint, treating these women as criminals isn’t helpful for either them or their babies to achieve the best outcomes. We’re doctors, not the police, so acting judgmentally has no role; we should be helping these patients and their babies in any ethical way possible.

Article title: “Evaluation of Ethics Education in Obstetrics and Gynecology Residency Programs.” In this study, 57% of OB residencies had 0-5 hours of ethics training, and 64% of residency directors said their graduates are unprepared or only somewhat prepared to handle ethically challenging situations. O&G‘s bottom line: “Obstetrics and gynecology residencies are behind in creating and evaluating formal ethics education programs.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Allocation of Ventilators in an Influenza Pandemic

A few weeks ago, the New York State Task Force on Life and the Law at the New York State Department of Health released updated guidelines on “Allocation of Ventilators in an Influenza Pandemic.”

In short, the Guidelines incorporate an ethical framework and evidence-based clinical data that support the goal of saving the most lives in an influenza pandemic where there are a limited number of ventilators.

The Task Force first released a report in 2007, addressing how ventilators should be allocated to adults in the event of a shortage due to a pandemic outbreak of influenza.  Those Guidelines were among the first of their kind to be released in the United States and have been widely cited and followed by other states.

In November 2015, the Task Force released its updated Guidelines. As part of the revision process, the Task Force oversaw an extensive public engagement project and incorporated these results and prior public feedback into the updated Guidelines. In addition, the ethical framework is more detailed, and the adult clinical ventilator allocation protocol has been expanded to include a more robust discussion of the clinical factors. 

Furthermore, the 2015 Guidelines examine special considerations and ethical issues related to the treatment of children and include two new clinical ventilator allocation protocols for pediatric patients (17 years old and younger) and for neonates (infants less than 28 days old). Finally, a substantial exploration of the various legal issues that may arise when implementing the clinical protocols for ventilator allocation is also provided.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.