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Dominic Wilkinson. Oxford Nuffield Medical Research Fellow James Martin 21st Century School Fellow University of Oxford. Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia?. Case.

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dominic wilkinson
Dominic Wilkinson

Oxford Nuffield Medical Research Fellow

James Martin 21st Century School Fellow

University of Oxford

Shedding Light on the Gray Zone:How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia?

slide2
Case

Shedding Light on the Gray Zone

  • Is it permissible to withdraw?
  • Is it permissible to continue treatment?

University Hospitals Bristol NHS Foundation Trust/PA Wire

Rutherford Seminars in fetal & neonatal medicine (2005) vol. 10 (5) pp. 445-60

shedding light on the gray zone
IntroductionShedding Light on the Gray Zone

“The treatment of infants should be based on what is perceived to be in their best interest.”

Pediatrics 2007;119:403

slide4
The Zero line view

0

Interests

Shedding Light on the Gray Zone

Life worth living (LWL)

“Intolerable”

Life not worth living (LNWL)

Burdens > Benefits

slide5
The gray zone

Shedding Light on 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.”

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slide6
Outline

Shedding Light on the Gray Zone

  • What is the gray zone?
  • Why is there a gray zone?
  • Are newborns different?
  • Where are the edges of the gray zone?

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slide7
The gray zone

Shedding Light on 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
slide8
Different gray zones

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0

0

0

Shedding Light on the Gray Zone

slide9
The Threshold view

0

Interests

Shedding Light on the Gray Zone

Upper Threshold

Lower Threshold

slide10
Why parental discretion?

0

Interests

Shedding Light on the Gray Zone

  • Overlapping interests
slide11
Why parental discretion?

0

Interests

Shedding Light on the Gray Zone

  • Overlapping interests
  • Uncertainty

LNWL

LWL

slide12
Why parental discretion?

0

Interests

Shedding Light on the Gray Zone

  • Overlapping interests
  • Uncertainty
  • Liberalism
slide13
Why parental discretion?

0

Interests

Shedding Light on the Gray Zone

  • Overlapping interests
  • Uncertainty
  • Liberalism
  • Parental interests

?

slide14
Are newborns different?

Shedding Light on the Gray Zone

  • Uncertainty?
  • Duration of uncertain prognosis?
  • Strength of parental rights or interests?
  • Harm of death?

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slide15
Where are the edges of the gray zone?

Shedding Light on the Gray Zone

  • Vagueness
  • Incommensurability
  • Too hard?

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slide16
Where are the edges of the gray zone?

Shedding Light on the Gray Zone

  • Normative criteria: Upper Threshold
  • Treatment 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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slide17
Where are the edges of the gray zone?

Shedding Light on the Gray Zone

  • Normative criteria: Lower Threshold
  • Treatment 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

?????

slide18
Where are the edges of the gray zone?

Shedding Light on the Gray Zone

  • Practical criteria:

Interests

Moderate impairments

Severe Cerebral palsy / Severe Cognitive impairment

0

Multiple severe impairments - especially combined with ongoing painful illness or medical intervention

slide19
Advantages of this account

Shedding Light on the Gray Zone

  • Avoids claim that severe impairments are LNWL
  • Allows scope for parental discretion
  • Advantages for care of older children
  • More consistency in decision-making

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slide20
Acknowledgements

Shedding Light on the Gray Zone

Professor Tony Hope

Professor 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?

dominic.wilkinson@ethox.ox.ac.uk