Abortion, particularly later-term abortion, and neonaticide, selective non-treatment of newborns, are feasible management strategies for fetuses or newborns diagnosed with severe abnormalities. However, policy varies considerably among developed nations. This article examines abortion and neonatal policy in four nations: Israel, the US, the UK and Denmark. In Israel, late-term abortion is permitted while non-treatment of newborns is prohibited. In the US, on the other hand, later-term abortion is severely restricted, while treatment to newborns may be withdrawn. Policy in the UK and Denmark bridges some of these gaps with liberal abortion and neonatal policy. Disparate policy within and between nations creates practical and ethical difficulties. Practice diverges from policy as many practitioners find it difficult to adhere to official policy. Ethically, it is difficult to entirely justify perinatal policy in these nations. In each nation, there are elements of ethically sound policy, while other aspects cannot be defended. Ethical policy hinges on two underlying normative issues: the question of fetal/newborn status and the morality of killing and letting die. While each issue has been the subject of extensive debate, there are firm ethical norms that should serve as the basis for coherent and consistent perinatal policy. These include 1) a grant of full moral and legal status to the newborn but only partial moral and legal status to the late-term fetus 2) a general prohibition against feticide unless to save the life of the mother or prevent the birth of a fetus facing certain death or severe pain or suffering and 3) a general endorsement of neonaticide subject to a parent's assessment of the newborn's interest broadly defined to consider physical harm as well as social, psychological and or financial harm to related third parties. Policies in each of the nations surveyed diverging from these norms should be the subject of public discourse and, where possible, legislative reform.
The implementation of a living will can give rise to ethical dilemmas for the patient's family and the health care professionals involved. The case reported here raises questions about the right of patients to self-determination, the importance of quality-of-life considerations in treatment decisions and physicians' obligations with respect to the implementation of living wills. Physicians should ensure in advance that the instructions set out in a living will are unambiguous and should bring to the patient's attention any ethical difficulties that they foresee in carrying out those instructions.
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The author reports on six months' experience of obtaining advance directives from patients for care in a family practice. Patients were questioned about their preferences for comfort or prolonging life and then were asked to delegate a substitute decision maker. Of 20 patients, all who responded chose comfort over prolonging life. Delegated substitute decision makers included spouses, children, and professionals or friends. In this population, patients overwhelmingly favoured comfort over prolonging life in the event that they might be irreversibly disabled, and they tended to choose spouses or other first-degree relatives as substitute decision makers.
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In Sweden, the official policy is that life-sustaining treatment should not be denied because of chronological age. This policy is also emphasised in a recent official report on priority setting in health care. But is this policy accepted among health care professionals? Do they consider chronological age relevant when decisions to forgo life-sustaining treatment are to be made?
Questionnaire survey to physicians, registered nurses and enrolled nurses at the Intensive Care Unit, University Hospital MAS, Malmö, Sweden.
More than 65% of the respondents were of the opinion that chronological age per se influenced decisions about life-sustaining treatment. Fewer, a little more than 40%, answered that it would make a difference to their own judgment about life-sustaining treatment whether the patient is 25 or 75 years old. The respondents were also confronted with 10 different factors characterising patients in need of life-sustaining treatment. According to a majority, advance directive, decision-making capacity, and chronological age should be taken into consideration in these situations.
The results indicate that chronological age is used as a criterion when decisions to forgo life-sustaining treatment are to be made in the ICU. Many health care professionals also believe that chronological age should be used as a criterion. This is clearly discordant with the official policy in Sweden and other countries, which is that age-based rationing is never justified.