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)

Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked to reflect on their ethics training and utilization of ECS via an anonymous, electronic survey distributed in 2017 and 2018, and analyzed in 2018. Participants reported their clinical experience, exposure to formal and informal ethics training, use of formal and informal ethics consultations, and potential barriers to formal consultation. Results: Less experienced pediatricians were more likely to utilize (...) formal ethics consultation and more likely to have formal ethics training. The most commonly reported reasons not to pursue formal ECS consultation were inconvenience and self-reported expertise in pediatric ethics. Conclusions: These results inform ongoing discussions about ethics consultation among pediatricians and the role of formal ethics training in both undergraduate and graduate medical education. (shrink)

Volume 20, Issue 7, July 2020, Page 77-80.

The ethical permissibility of the “slow code” sparks vigorous debate. However, definitions of the “slow code” that exist in the literature often leave room for interpretation. Thus, those assessing the ethical permissibility of the slow code may not be operating with shared definitions, and definitions may not align with clinicians' understanding and use of the term in clinical practice. To add clarity and nuance to discussions of the “slow code,” this manuscript highlights the salient medical and moral components that distinguish (...) resuscitative practices, resulting in a taxonomy that includes nine distinct entries: the Fake Code, Casual Code, Time‐Limited Code, Family Code, Contained Code, a la Carte Code, Preventive Code, Passive Code, and Accepted Code. We argue that cogent analyses of the ethical implications of the “slow code” must begin with clear, shared understandings of the practices under debate. (shrink)

Volume 20, Issue 6, June 2020, Page 40-42.

In “Postponed Withholding: Balanced Decision-Making at the Margins of Viability,” Syltern et al. (2022) propose a novel approach to life-and-death decision making for extremely preterm infants in t...

Background This study assesses how pediatric assent is conceptualized and justified within the therapeutic context. Pediatric ethicists generally agree that children should participate in medical care decisions in developmentally appropriate ways. Much attention has been paid to pediatric assent for research participation, but ambiguities persist in how assent is conceptualized and operationalized in the therapeutic context where countervailing considerations such as the child’s best interest and parental permission must also be weighed.Methods Searches were conducted in 11 databases including PubMed, Embase, (...) Cochrane Library, and Web of Science. Articles published between 2010 and 2020 were screened in COVIDENCE for meeting each of four criteria: (1) focusing on pediatric assent, (2) focusing on clinical care, (3) including normative claims, and (4) containing substantive statements about the meaning of pediatric assent. Full texts were abstracted for (1) operational definitions of assent, (2) discussion of the temporal nature of assent, (3) description of the concept of “understanding,” and (4) ethical justifications for soliciting assent. These excerpts were coded and code patterns formed themes presented in the results.Results The final analytic data set contained 29 articles. Analysis yielded three key themes. First, valid assent varies by treatment, population (e.g., younger versus older), and geographic/cultural context. Second, assent represents two distinct longitudinal processes: One involves eliciting preferences over a disease course or care episode; the other focuses on children’s developmental maturation. Third, ethical justifications for assent draw variously on instrumental and intrinsic reasons, but often remain ambiguous.Conclusions There is widespread agreement that assent is morally valuable, but there remain substantial ambiguities or disagreements about its meaning, process, and ethical justification. (shrink)

In the development of new vaccines, many trials use age de-escalation: after establishing safety and efficacy in adult populations, progressively younger cohorts are enrolled and studied. Age de-escalation promotes many values. The responsibility to protect children from potential risks of experimental vaccines is significant, not only given increased risks of adverse effects but also because parents and medical professionals have a moral responsibility to protect children from harms associated with novel, uncertain interventions. Further, given that young children cannot provide informed (...) consent, acceptable risks for research requiring proxy consent are lower than for adults making decisions for themselves. Although age de-escalation approaches are widely used in vaccine trials, including notably in the recent development of pediatric COVID-19 vaccines, ethicists have not addressed the benefits and risks of these approaches. Their benefits are largely assumed and unstated, while their potential risks are usually overlooked. There are no official ethics guidelines for the use of age de-escalation in clinical research. In this paper, we provide a systematic account of key moral factors to consider when employing age de-escalation. Analyzing pediatric COVID-19 vaccine development as our key case study, we clarify the benefits, risks, and trade-offs involved in age de-escalation approaches and call for the development of evidence-based best practice guidelines to identify when age de-escalation is likely to be an ethical strategy in vaccine development. (shrink)

The American Journal of Bioethics, Volume 12, Issue 4, Page 17-19, April 2012.