Paradigm Cases in Decision Making for Neonates

Abstract

After completing this article, readers should be able to: 1. Describe potential problems with interpreting legal cases relating to neonates who have disabilities. 2. Trace the evolution of legal decisions regarding neonates who have disabilities. 3. Describe the Baby Doe rules and their ultimate revision. Just as clinical practices, methods of diagnosis and therapy, and technology have evolved dramatically over the past 40 years in neonatology, so too have the ethical and legal dilemmas that clinicians face. This evolution is not peculiar to perinatology and neonatology; it also has occurred in pediatric and adult intensive care. Clinical situations that raised serious ethical questions 20 years ago are now common, everyday clinical events (eg, do not resuscitate orders, withdrawal of mechanical ventilation or dialysis, withdrawal of gastric feeding tubes). The history of the important or “classic” or “paradigm” cases in a field reveals much about how the issues have evolved, how clinical decisions are made today, what factors are currently seen as important in a case, who should participate in decisions, how much power each decision maker has in a decision, and why clinicians behave the way they do. Some of the important cases progressed through state or federal legal systems; some cases were tried in the criminal system and others in the tort system. Many, however, appeared as interesting or provocative case reports and discussion in the literature. Especially for those that have been decided in the court system, each case often is used as an example of a key legal or ethical principle or a revolutionary event or phenomenon in clinical decision making. Unfortunately, this frequently represents an oversimplification, at times a misrepresentation, of what can be complex issues, in which the primary issues that raised the profile of the case may not finally be the issues for which the case becomes …