In a crisis, societal needs take precedence over a patient’s best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. (...) But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When “triaging” or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies. (shrink)

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: (...) i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end. (shrink)

Ethically complex and challenging cases confront health care professionals in neonatal‐perinatal medicine more often than in most other subspecialties in medicine. Neonatologists regularly encounter situations where crucial life‐or‐death decisions need to be made in the best interest of an infant and its family. While physicians and their professional societies seem to dictate this best interest standard by weighing the risk of mortality and morbidities, parents may have other perspectives to be considered.Our review of programs for teaching ethics in Canadian neonatal‐perinatal (...) residency programs has revealed that 90 percent of them incorporated formal and informal medical ethics education, meeting the Royal College of Physician and Surgeons of Canada requirements, but that the teaching strategies, topics covered, and time devoted to teaching ethics are not standardized. Lectures and case presentations—the pedagogic strategy used by most programs—are not ideal for teaching communication skills. We propose, therefore, a holistic approach to teaching and training that imparts (1) a traditional understanding of ethical theory and reasoning, (2) advanced skills in communication and counseling, and (3) a disposition to engage in self‐reflection and to be aware of the emotional and spiritual dimensions of neonatal‐perinatal medicine. (shrink)