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scientists react to Nuffield Council on Bioethics report on critical care decisions in foetal and neonatal medicine

A report from the UK’s leading bioethics body has recommended that babies born at or before 22 weeks should not be resuscitated or given intensive care and that those born at 23 weeks should be treated giving consideration to the parents.

John Wyatt, Professor of neonatal paediatrics at UCL, said:

“I welcome this thoughtful, detailed and balanced piece of work and I particularly welcome the strong statement against the intentional ending of life in critically ill babies.

“But I have some areas of concern. This report puts great emphasis on managing babies by their gestational age and provides week by week guidance. However in practise assessing the maturity of babies can be unreliable and can vary by up to two weeks. Although I welcome the guidelines, I believe that doctors must continue to individualise care in each unique situation – in other words cut off times don’t necessarily fit neatly with clinical practise.”

Professor Allan Templeton, President of the RCOG (Royal College of Obstetricians and Gynaecology), said:

“There are many complex and controversial issues regarding the care of very premature babies. These guidelines will help maternity and neonatal staff to make difficult decisions in consultation with parents, and to provide the best care available to those that need it.

“Ultimately, obstetricians make every possible effort to look after mothers and their unborn children – their safety and wellbeing are of paramount concern to those in our specialty. The Nuffield Council’s recommendations will help us to manage the clinical situations further and offer the best evidence-based advice to families.

“As the report indicates, difficult decisions have sometimes to be made, when a problem is identified with the health of the foetus or late termination of pregnancy is considered. Further guidance is required in this area.”

Kate Costeloe, Honorary Consultant and Professor of Paediatrics, Homerton Hospital NHS Trust, said:

“This report gives very clear guidance about the legal framework which currently confuses some paediatricians.

“Personally I welcome the reports strong views on euthanasia. Similarly I welcome the emphasis on the difficulty of adopting the right course at 23 weeks. The week by week approach is fine but there seems to be only scant note of the fact that many of these women pitch up in unexpected labour at a hospital other than where they have booked and that the staff may be uncertain about gestation and little opportunity to gauge the views of the parents. The importance of skilled paediatric assessment at birth cannot be overemphasised.

“I have found no reference in the report to the importance of quality of care. While it does describe the need for investment in research and training it does not highlight the point that many very preterm babies are born and receive continuing intensive care in hospitals without 24h access to staff with specialist training. Further investment is needed to insure equitable access to care appropriate to clinical need.

“I think the issues around withdrawal of intensive care from babies doing badly are even more fraught. I am acutely conscious of situations where doctors are providing care against what they perceive to be the interests of the child because of parental pressure, sometimes because of reluctance of being accused of racism and religious bigotry. The guidance about using clinical ethics committees is good but I think those sections might have been stronger.”

Tom Shakespeare, social scientist and bioethicist at Newcastle University, said:

“The Nuffield Council on Bioethics report rejects the active ending of life of newborn babies, and has called for better and more consistent support for disabled children and their families. This is warmly to be welcomed. Decisions about care of very premature newborns are complex and distressing, but it is unclear how the new Nuffield guidance changes existing practice in neonatology: in all cases, decisions should come after careful discussion between parents and clinicians about the best interests of the baby. The fact that a surviving baby might be disabled should not be a factor which leads to withdrawal of treatment: futility of treatment and unnecessary suffering of the baby should be the main considerations.”

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