Decisions regarding resuscitation of the extremely premature infant and models of best interest

Abstract

Differences concerning the care of an extremely premature infant may stem from alternative points of view on how to determine the infant's best interest. These alternatives are illustrated by differences between recently published statements by the American Academy of Pediatrics (AAP) Committee on Fetus and Newborn (COFN) and the Committee on Bioethics (COB). The statements agree that a goal of neonatal medicine is to minimize both under- and overtreatment of the extremely premature infant, and advocate that the decision-making process ought to be based on the concept of the premature infant's best interest. However, the two AAP Committees appear to diverge in how they operationalize the concept of an infant's best interest. The COFN adopts a process consistent with an "expertise" model of best interest, while the COB process is consistent with a "negotiated" model. In the "expertise" model, medical re-evaluation of the infant's status, the best outcome data available, and the treating physician's best medical judgment determine best interest. This model limits parental and societal input, and can lead a physician to act paternalistically. In the "negotiated" model, best interest is determined by outcome data and physician assessment, as well as the moral value of an outcome. This model maximizes parental input, accepts physicians as moral agents, and respects social influence in a decision. It is important to clarify one's model of best interest to help understand the differences of opinion regarding decisions based on best interest. The negotiated model of best interest is a more ethically appropriate model to approach decision making.