MEDICAL

ETHICS
 Format
What is ethics
Why ethical issues more imp . In medical Profession
Virtues making medical practice a profession
Principles /guidelines of ethics
Model of ethical decision making in clinical settings
Illustrative examples for these principles
Pediatric ethical issues
Neonatal ethical issues
Rights of Fetus & Indian law .
Scenarios
What do we mean by “ethics”?
Ethics is concerned with human well-being,
and with the maintenance of a peaceful society.

Ethics: “The science of morals in human

conduct”.

What are “morals”?

Goodness and badness, distinguishing
between right and wrong.
Ethics:

Criteria for guiding human action.

A code of conduct, or guidelines, for what

we should do in a given situation.
Simplest :Doing Good
 Why Ethical issue more imp in med profession
Noblest profession
Professional means Good Conduct & Virtuous behavior
supreme responsibility of preserving life and maintaining health
Considered demi Gods Unstinted faith reposed by patient in a
doctor

Charaka
– “ No other gift is greater than the gift of life, The patients may
doubt his relatives , his sons and even his parents but he has
full faith his physician. He himself up in he doctor’s hand and
has no misgivings about him . Therefore it is the duty of the
physician to look after him as his own . ------”
– A physician should e Virtuous & a man of Character
 Virtues making medical practice profession
Fidelity of trust
– Imp virtue of human relationship
– Telling truth
– Being consistent , having Integrity ,
– Doctor is Trusted for being competent , trained , acting
unbiased & helping
Doctor must honour Fidelity of trust . Must be trustworthy .

Compassion
Com =with , Passion = suffering ( it is beyond pity
Pity = just feeling sorry for he patient’s condition
Empathy =just Understanding the suffering of the pat.
Most desirable quality
distinguished Doctor from merely having tech knowledge and
applying it .
 Virtues – contd
Phronesis ( common sense )
Aristotle used this word
Having practical Wisdom
To have moral insight
Ability to assess situation
Decide right course of action & execute it
Justice
( rendering one what is his due )
Physician : render to patient , family , community & nation
physician has to do justice balancing Autonomy economic
pressures , personal beliefs
Fortitude
( Total courage = Physical + Mental + Emotional Courage )
more than Valor of a soldier in battle
caring for HIV patient
after hrs working
facing criticism from clientele
 Virtues
• Temperance /Prudence
use technology with prudence
think twice before rendering the newest & latest .
• Integrity
( bringing all parts to gather )
outward projection of giving Hope , predictability at the same
time being realistic
No role of façade of self confidence
calls for Ongoing self examination
• Self Effacement
( knowing your place // Not to feel superior than others )
doctor is trained , skilled & knowledgeable
Does not mean feel superior to patents/patients.
Situations of application of ethics

Medical ethics may be applicable in . . .

Individual patient problems
Health resource allocation
Patient and health care research
Where can we find these guidelines? Are they
written down, or codified, somewhere?
In religious tracts (eg, Bible, Koran)
Professional code of conduct (eg, Hippocratic oath)
Hospital policies
Medical authority (eg, the Constitution of a Medical
Association)- FMA
The laws of the country or jurisdiction
Consensus in the community
One’s own intuition and feelings about what is right and
wrong
Principle-based ethics: /Guidelines

Based on the idea that it is possible to specify

certain rules or “principles” to guide moral
actions.

The most widely-used example is the “four-

principles” approach of Beauchamp and Childers.
Principle-based ethics: ( A-BMJ)
The four principles currently used by bioethicists
when considering ethical problems, solving
ethical dilemmas, to arrive at ethical decisions:
1) respect for autonomy
2) beneficence
3) non-maleficence
4) justice
1. Principle of Respect for Autonomy:

Autonomy = “self-rule”
Each person is his or her own moral agent, and has
a right to make decisions about himself or herself
without interference.
1. Principle of Respect for Autonomy:

However . . .
• Where does the responsibility of the patient end,
and the responsibility of the doctor begin?
• If the patient is unconscious, who is ultimately
in charge of making an ethical decision?
• The doctor?
• The spouse?
• The family?
• Who has the ultimate authority when there is a
conflict between the decision-makers?
2. Principle of Beneficence:

Beneficence = “to do good”

The decisions we make, and our conduct in

carrying out those decisions, should be aimed at
ensuring the greater good and well-being of our
patient.
2. Principle of Beneficence:

Treat the illness, cure the disease, return the patient

to good health.
However . . .
What if the disease is incurable? How do we
ensure the good and well-being of our patient?
• then just . . . relieve suffering and pain
• . . . provide comfort and support

Are there limits to the comfort and support we

should provide for our patient? How much is
enough? When does enough become too much?
3. Principle of Non-Maleficence:

Non-maleficence = “above all, do no harm”.

The decisions we make, and our conduct in

carrying out those decisions, should not harm our
patient. The decisions should cause no harm to
others either.
3. Principle of Non-Maleficence:

However . . .
• Aren’t some forms of treatment harmful?
• How much pain may we inflict in bringing
about the good and well-being of our patient?
• How do we balance the risks and the burden of
treatment, against the burden of illness?
• And what if treatment is ‘futile’, without hope
of cure?
Beneficence and non-maleficence must be
balanced.
4. Principle of Justice :

Justice = “to give one & all –what is their due”

Justice means being fair, striving for an equitable

judgment between competing claims.

Justice and equity in health care issues imply that

everyone should have an opportunity to attain his or
her full potential for health.
Regarding these principles:
Each principle is ‘prima facie’: in other words,
each principle has equal weight, and can be
over-ridden by one of the other principles.
There is no hierarchy of principles: each is
essentially of equal importance, and must be
balanced against the others.
The principles are not “rules”, but serve as a
framework for considering ethical issues in
health care.
Clinical Ethics:

Provides a process for sorting through ethical

problems which arise when taking care of patients.
Does not provide protocols / prescriptions
intended to cover every possible ethical dilemma.
Provides a process when faced with difficult moral
choices, in order to arrive at a decision as to how
to act.
 Model for
ethical decision-making
in a clinical setting
(from Kerridge I, Lowe M, McPhee J: Ethics and Law for the Health Professions, Social Science
Press, 1998)
1. Clearly state the ethical problem

• Distinguish the ethical aspects of the problem,

• Sepatare Ethical problem from
• other medical,
• social,
• and legal issues.
2. Determine the facts

Gather as much relevant information as

possible
from the present history
past history
social history
clinical examination
investigatons
3. Consider the four principles on which ethical
decision-making is based:
Autonomy: What is the patient’s desire?
Beneficence: What is in the best interest of the
patient?
Non-maleficence: What are the risks to, and
burdens on, the patient, and how can they be
minimised?
Justice: How do we balance the interests of all of
the parties involved?
4. Identify ethical conflicts.

• What are the ethical conflicts?

• What is the basis of the ethical conflicts?
• Why are they occurring?
• How can the ethical conflicts be resolved?
5. Consider any legal aspects.

• Are there legal considerations that may serve as

a guideline?
• Do the legal aspects lay down cetain bindings
(abortions)

What is the relationship between the clinical-

ethical decision and the law?
6. Make the ethical decision, and justify it.

• Make ethical decision

• Balancing all competing interests
• Adreessing all conficts
• As per guide lines
• As per law
• In the best interest of the patient , society &
family

29
6 State the basis of the decision, the guidelines
30 used, and how competing considerations were
balanced. Take responsibility for the decision.

Document the decision.

Evaluate and follow up on the decision.

Terri Schiavo, a 41 year old woman, suffered
hypoxic brain damage 14 years ago.

Her husband wishes to remove her feeding tube,

and allow her to die, as he feels there is no hope
that she will get better.

Her parents disagree with this decision, and wish

to keep the feeding tube in place, as they feel
there is a chance she might get better.
The facts of the case:
Theresa Marie Schindler married Michael Schiavo in 1984.
They had no children, despite Terri’s attempts to become
pregnant. She had started consulting a fertility specialist.
Terri was overweight as a teenager, and had recently lost
much weight by dieting.
In the middle of the night one night in February 1990, Terri
suddenly collapsed. By the time she was eventually revived
by paramedics, she had suffered severe hypoxic brain
damage.
She was diagnosed as having had a cardiac arrest caused by
a severely low serum potassium. She was 26 years old.
The facts of the case . . .
In June 1990, her husband took her to California for
experimental brain therapy, which proved unsuccessful.
 

She lived ever since then in a nursing home in Florida.

Given food and water by feeding tube. Nurses changed her
diapers.
Over the next several years, as a result of numerous
examinations, evaluations, investigations by many
specialists, it was determined that Terri Schiavo was in "a
persistent vegetative state."
The facts of the case . . .

“Persistent vegetative state”:

• "cycles of apparent wakefulness and apparent sleep
without any cognition or awareness"
• "much of the cerebral cortex is simply gone"
How were the principles of ethical decision-
making applied in this case?

1) Respect for autonomy

2) Beneficence
3) Non-maleficence
4) Justice
Autonomy:
 
Who is the moral agent able to make ethical
decisions in this case?
• The patient?
• The husband?
• The parents?

“Advanced directive” ( = “living will”)

Beneficence:
 

How do we ensure her good and well-being?

• Can her illness be cured? Is there any chance for
recovery? Is there a possibility she may improve?
• Can her suffering and pain be relieved?
How may we provide comfort and support?
• Are there limits to the comfort and support we
should provide?
“Is providing food and water by a feeding tube,
ensuring her greater good and well-being?” 
Non-maleficence:
 

How do we avoid causing harm?

Will our treatment cause this patient harm?
• If her illness can not be cured,
• . . . if there there is no hope for recovery,
• . . . if there is no possibility of improvement
in her condition . . .
. . . is treatment / comfort / support harmful?
“Might providing food and water by a feeding
tube, be harmful to this patient?”
Balancing beneficence and non-maleficence:
 

Sanctity of life:
• It is prohibited to intentionally kill a person,
to intentionally let a person die, or to base
decisions about prolonging or shortening life
on the quality of a person’s life.
• Exceptions are often made . . .
. . . for example, if the outcome is
considered excessively burdensome for
patients.
Balancing beneficence and non-maleficence:
  Ordinary vs Extraordinary means of treatment . . .
• Ordinary means of treatment: patients are
morally obliged to accept, and health
professionals obliged to offer
• ‘Extraordinary means’: morally optional, and
may be refused.
Balancing beneficence and non-maleficence:
  Ordinary vs Extraordinary means of treatment . . .
• ‘Ordinary means’: treatment which offers a
reasonable hope for benefit, and which does not
involve excessive expense, pain, or other
inconvenience.
• ‘Extraordinary means’: treatment which
involves excessive expense, pain or
inconvenience, and does not offer a reasonable
hope of benefit.
Balancing beneficence and non-maleficence:
 

Burdens and benefits of treatment are weighed:

• Benefits of treatment: improvements in life
expectancy, physical functioning, decreased
pain, improved overall quality-of-life.
• Burdens of treatment: risks; pain, discomfort,
or distress it may cause; negative impacts on
patient’s life; psychological effects; costs.
Balancing beneficence and non-maleficence:
 

Burdens and benefits of treatment are weighed:

• If burdens greatly outweigh the benefits of
care, the treatment may be considered
‘extraordinary means’ . . .

. . . and hence may be refused

Beneficence vs non-maleficence:
 

The doctrine of ‘futility’

• Patients should not be forced to undergo
treatment that is judged to be futile, nor should
the therapist be under any obligation to offer it
Justice:
 
How to balance the interests of all parties involved?

How to balance the interests of the patient

. . . with the interests of her husband

. . . with the interests of her parents

. . . with the interests of the community

What are the legal aspects in this case?
The courts . . .
• accepted the diagnosis of “persistent vegetative state”
• agreed that the husband was the patient’s legal
guardian, hence empowered to make decisions for her
• accepted the husband’s declaration (in lieu of a “living
will”) that the patient stated on several occasions she
would not want to be kept alive artificially
• agreed that providing food and water by feeding tube
was an undue burden for someone in a persistent
vegetative state with no hope of recovery or
improvement
• ordered the feeding tube removed
How does this case demonstrate the four
principles of ethical decision-making ?

1) Respect for autonomy

2) Beneficence
3) Non-maleficence
4) Justice
 Pediatric issues
The Best Standard
( providing care which is in best standard of the patient )
– Usually guardian , legal appointee take decision
– Young child , mentally incapacitated
– Emergency situations
Parents Right
– ( give authority to parents in decision making )
– Intimately involved in child’s care
– Longer / life time involvement in care of the child
Exceptional Situations
– ( refusal of parental authority and right )
– Jehovah ‘s witness sect – blood transfusion refusal .
– Or refusal of surgery for a correctable anomaly
– US – doctor can seek court order
– Place the child in custody of the state
 Pediatric issues
Minor /Teenager parents
– ( cant take decision about self but now master of heir
own child )
– By & large minor parent is to be given decision making
status
– At times grand parents contribute to decision making
– Finally grand parents don’t override minor parents unless
mentally incapacitated .
Prenatal child abuse
– Normally physical /emotional abuse post nataly
– IV Cocaine by pregnant mother is Fetal abuse Legally –ca
be prosecuted
– Child become ward of the state
–
 Neonatology issues
Informed consent
– ( inform details + obtain Consent )
– Inform complication , therapy , procedure , long term
implications
– Offer alternative remedies
– Evaluate parents capability to take best interest decision
– Do they understand dis , complication , treatment options ,
prognosis
– At last major & common complications should be informed
– Silence should not be taken as Consent
– Obtain Written & durable consent
– Discuss potential problem which can arise in emergency
 Neonatology issues

Withholding Care
– Highly technical procedure may not be in the Best interest
of pt
– Think Intended therapy
– Will have intended effect ?
– Reverse he process?
– Will provide acceptable quality of life?
– Discuss with parents /other professionals //nurses
 Neonatology issues
Withdrawing care
– Futile care – intended purpose not served
– Changed diagnosis ,prognosis –re-discuss
– Care given in emergency if contrary to parental wishes
E.g Vasopressor in moribund case
– Depends on Definition of futility
Use compassion , Phronesis , compassion & discuss .
Nutrition & Comfort
– Nutrition as a therapy can be withdrawn
– Nutrition as basic comfort is patient’s right
– Consensus
Must be given Nutrition, pain relief , physical & Moral support
Involve parents , bioethics committee, legal authorities
 Neonatology issues

Delivery Room issue

– Setting of quick assessment & rapid decision
making
– For viability , quality of life , prognsis
– E.g extreme preterm lethal anomalies
– Follow foll principles
Discuss in advance expectation of parents
Co-ordinate with obstetrician
Err on side of life – decision can be revised
No resus :AAP <23 weeks , <400 gms
Discontinue Resus :if no spontaneous ciru after 15 mts
Each hospital should have own criteria .
 Conflict resolution
Conflict ( dispute or difference of opinion )
(Parents doctor , nursing staff, admin )
– Identify conflict
Open , Honest and continued communication resolves
Continued communication unfolds unvoiced concerns & issues
– Putting virtues in Practice
Virtues if practices diffuse conflict s , resolve issues
Dialogue corrects miscommunications
– Bioethics consult
Obtaining outside perspective
Other doctors /institution
It is Not seeking more Expert opinion
It is resolving Moral conflict , miscommunication , by More
Minds
 Conflict resolution
– Bioethical committee
Doctor , admin , nurses , clergy , legal people
Monitors ethical conduct of doctor & staff
Resolves conflicts
Makes policies & guidelines
Liaison with judiciary
Procedure o seeking involvement Bioethical committee be
appraised to parents
– Legal systems
Resort t o judiciary when conflict not sorted out otherwise
Bioethics committee maintains liaison with legal system
Can frame the question appropriately for Desired response
Protects physician from litigations
 Right of fetus & Indian law
Manu : Fetu s has right t live and inherit property
IPC 1860 fetus is a living being , any person
causing will ful death death of fetus wil be
punished .
1971 MTP Act ( abortion lberlisation )
– <12 weeks – RMP can terminate pregnancy
– 12- 2- weeks – Two RMP can take decision
– >20 weeks doctor can terminate pregnancy to save the
life of mother
– No USG sex determination of the fetus and selective
feticide .
– Display welfare to the lives of both (mother & fetus )
– Mother’s life be considered more precious .
Can pregnancy >20 weeks be terminated ?
20 weeks cut off point because fetus
becomes viable and abortion fraught with
dangers .
Beyond 20 weeks foll. conditions be met
with
– Fetus afflicted with condition which is ,
incompatible with life or meaningful survival ,
total /virtual absence of cognitive functions.
– Prerequisite –parental diagnosis of the
condition must be 100 reliable
– Reliability be ascertained by group of experts
– Informed consent of the parents be obtained
Lethal Congenital malformations
1.An encephaly
2.Hydran-encephaly
3. Holoprosencephaly
4. Trisomy 13 ,17 ,18
5. Triploidy
6. Renal agenesis
7. Sironemelia
8. Short limb dwarfism syndromes
9. Misc : Pterygium syndrome , Mecekl Guber
Syndrome , Neu – Lexova syndrome
Is it justifiable to have NICU level III in developing
countries
Large number of salvageable babies dying in community
Vs few with lethal conditions getting level III services
Neonatal services :cost –intensive , cost –effective ,cost
benefit ratio
Ethical act will be to distribute resources in such a manner
that equal services be rendered to all babies at home , PHC
, CHC , district hospital , tertiary care center ( the how
tertiary care – conflict )
Recommended is equitable delivery of services to al
neonates – Grass root or Tree Top
Develop and ensure and speedy & effective referral system
No referral & evacuation after delivery of crucial component
of service – no use of Level III NICU .
Saving life of a newborn is more for national productivity
than a person with cardiac or cerebral stroke ( will die in 2-
5 yrs) .
 Withdrawing withholding Life support
“baby Doe “ all new born should receive maximum life support .
Selective Non treatment :accepted in severe neuro-muscular
disability
Follow Utilarian Ethincs ( value for Money )
Selective non treatment must be recorded in documents with
scientiic justification and parental consent .
All NICU , Nations should form own policies .
Withdrawal of life support – same principles ( brain
death/nonmeanigful life)
– Extreme Preterm with PV – IVH
– Severe asphyxia – no resp effort >30 mts
– Persistent Vegetative State.

Offer TLC ie warmth , Nutrition , Hydration . Pain relief &

compassion .
– For all Lethal conditi ( vide supra )
– <750 gms & < 26 wks.
 Communication –enhance doctor – parent
relationship
Crucial to generate faith & trust
Never be abrasive /unsympathetic.
Communication , Care , Concern , Compassion COVER
chaos u may create .
What to tell ?, How to tell ?
Be truthful & Honest
Talk to both / other family members
Simple language
Eye to Eye contact .
Keep Hope Alive ( ?? Hope has healing cpabilities)
Allow parents to touch & talk to baby
Not only do the best , BUT be Perceived doing the best .
Honour religious faith of the family
 Ethical dilemmas :Misc
Death must be accepted as ultimate truth as medicine can never attain
immorality
Brain dead pregnant woman : should she be maintained on life support for
baby ?
Dilemma in perinatal medicine is more because at times it is IMPOSSIBLE
to predict immediate survival and possible neuro-develo- outcome in
future ( William Osler “ medicine is a science of uncertainties and Art of
probabilities )
Major decision making problems
– Severe birth Asphyxia
– Lethal congenital conditions
– ELBW & preterm
– Terminally sick on life support

Maurice King
– “to stabilize population dynamics in developing countries , health care activities
including immunization should be withdrawn so that nature is allowed to take its
toll to eliminate the unwanted weaklings and weanlings from the society “
 Ethics : organ Transplant
India Organ transplant legalized 1994
No criteria for brain death for Preterm an Term <7 days
– Absent brain stem reflexes >48 hrs
– Two EEG , 48 hrs apart – electro-cerebral silence
– No CBF for >1 hr on Xenon PET
– ( obsn period may be increased to 72 hrs in Preterm <32 weeks )
Anencephalics vs Organ transplant

Should Anencephalics be excluded

from these criteria of Brain death for
Transplant purposes
Should here be separate criteria for
Anencephalics ?
 Surrogate mother issues
Sperm & ova from biological parents – no issues
Donated sperm / ova
– Confidentiality issue
– Strained Husband /wife relationship
– Neglect of child
– Congenital malformation
– Issue of paternity
– Right to property
Commercial hiring of uterus – Is uterus for sale - laws : if
any ?
Hired womb impregnated by Act of Sex – Morality Issue
Future : genetic engineering , cloning – plethora of moral &
ethical issues
 Perinatal HIV
15-30 % chance of Vertical transmission
Zidovudine & LSCS reduce incidence
15 % chances by breast feeding
Abortion – should that be offered to mother
Breast feeding : should or should not ??
Confidentiality issues related to abortion and not allowing breast
feeding
 Conclusions
Ethical decisions in perinatal medicine are difficult & complex.
Have socio-economic dimensions
Beneficence – Be Global ie interest of he family /society /nation .
Medicine is dynamic and Medical ethics are more dynamic
What was lethal y’day – to day is treated by Technology
Ethical perspective will change with advancement of medicine
Put yourself in place of parents and think
Take joint decisions with family /experts within prevalent legal
framework
Have Bioethics & Grievance redressal systems n Hospitals .
Let technology not dehumanize medicine .
All Medical schools should have programmes in Behavioral
sciences , communication & medical ethics s
Scenario #1:

Pita is a 56-year-male
recent history of haemoptysis.
frequent chest infections in the past,
Chronic smoker
wheezes on auscultation,
firm hard immobile non-tender supraclavicular lymph node
negative for AFB, chest Xray + bronchoscopy – BGC

Doctor wants to discuss

Wife – says NO – Pita will loose Hope

What should the doctor do for Pita and for his family?
What are the doctor’s responsibilities?
What are his options?
What would you do?
How would you justify your decision?
Scenario #2:
Eric is a 35-year-old sailor – genital discharge
History of STIs ( gonorrhoea & syphilis ) teratment many times .
does not use Condom
has a wife and two children at home.
His wife is currently pregnant with their third child.

Investigations
gonorrhoea +ve
HIV done without consent +ve
. Eric
dos not beliee being HIV +ve
Does not want wife to be informed .
What should the doctor do for Eric?
for his wife?
What are the doctor’s responsibilities?
What are his options?

What would you do?

How would you justify your decision?
Scenario #3:
Mrs Deo is a 69-year-old woman
multiple strokes , hemiparesis, aphasia but understands
and spends most of her time in bed,
being cared for at home by her daughter and grandchildren. She’s
suffers UTI – reeponds to AB
Admitted with
worsening of condition , dehydration , loss of weight
pulls IV , feels mnetally better without IV
What to do
restrain her , give IV?, left alone , - allow to die with dehydration ,
malnutrition , infection

. What should the doctor do for Mrs Deo? What are the doctor’s
responsibilities? What are his options?
What would you do? How would you justify your decision?
Scenario #4:
Theo is a 9-year-old boy Rheumatic Heart Disease,
Diagnosed at 6 as RhD MR
On LA Penicillin
Now has cardiomegaly and is on t/t for CCF

A visiting medical specialist recommends overseas t/t

MOH refuses due to Hx of poor compliance
Parents angry .

What should the doctor do for Theo? What are the competing interests in the
decision to be made here? What are the doctor's responsibilities? What are
his options?
What would you do? How would you justify your decision?
NHN 520239838 BABY of Roshani Singh
Nonconsanguineous parents, term female , DOB 14/05/2007.LSCS
mum, 34-year ,38 weeks gestation , antenatal USG- IUGR
gestational diabetes/ on diet control.
Upon delivery minimal resuscitation, APGAR was 4, 7, and 8 at
1,5,10 minutes Term , weighed 1.44kg.
Noticeable was deformity on the lower half of the body: bilateral
flexion contractures of the lower extremities due to popliteal webs,
and no palpable vertebral column in the lower back..
A whole body x-ray done showed essentially normal heart and lungs,
normal bowel gas patterns; about eight pairs of ribs observed; absent
lower thoracic, lumbar and sacrococcygeal regions; joint contractures?
Bilateral phalangeal abnormalities? Hip dislocation; fibula appears
hypoplastic; suggestion of bilateral clubfoot.
Overall appearances suggest caudal regression syndrome.
Currently, the infant is admitted to NICU-she is in an incubator,
breathing in room air, and tolerating breast feeds, passing urine and
stool well. Her blood results on 29/05/2007-Hb 15.8, Platelet 373000,
WCC 17800, Ur 5.8 Cr32 Na138.
She is also receiving meropenem for treatment of neonatal sepsis.
This medical report has been issued upon the request of the parents
who want to seek further medical advice overseas.
What should the Pediatrician do ? Responsibility / options ?? How do
you justify your decision ?
Active reconstructive surgery ? Active resuscitation /ventilation ???
Anenecephaly
Anenecephaly
Anenecephaly
 Baby K born anencephalic state on
October 13, 1992, at Fairfax Hospital in
Virginia.
No brain , only Brain stem which maintained hert , respiration and
autonomic functions
Mother knew antenatally , declined abortion on relegiousgrounds “
"all life is precious" & God alone should decide how long the baby
would live,
Mother adamant . Hospital auth – care futile .
Mother prevailed Advanced Life support offered. despite generally
accepted fact that anencephaly is not curable or treatable, and
that maintained life support would be both futile and wasteful.
Fairfax Hospital doctors advised a Do Not Resuscitate.
The mother refused the
Baby K. was left on ventilator support for 6 weeks
Fairfax searched for other hospital – none accepted .
After discharge
. H. agreed to move the child to a nursing facility,
but the baby returned to the hospital many times for respiratory
problems
 Baby K
At 6 months old, Baby K. admitted - severe respiratory problems.
The hospital filed a legal motion to appoint a guardian for the child's care,
and to declare that the hospital did not need to provide any services beyond
palliative care.
At the trial expert - ventilator support for anencephaly beyond accepted
standard of care.
Mothers advocate - sanctity of life principle .
U. S. District Court ruled that the hospital must ventilate if there is
trouble in breathing .
The court interpreted the
Emergency Medical Treatment and Active Labor Act (EMTALA) to require
continued ventilation for the infant.
The wording of this act requires that patients who present with a
medical emergency must get "such treatment as may be required to
stabilize the medical condition" before the patient is transferred to another
facility. The court refused to take a moral or ethical position on the issue,
insisting that it was only interpreting the laws as they existed. As a result
of the decision,
Baby K was kept alive much longer than most anencephalic babies, living
to age 2½ .
Some commentators on the decision argue that it effectively turned
doctors into mere "instruments of technology", and took away a doctor's
prerogative to make responsible, utilitarian medical decisions.
 Effects of Baby K. case

The case of Baby K. is of particular importance to

clinical bioethics because of the rich variety of
issues it raises:
defining death, the nature of personhood, the
notion of moral standing, medical futility, caregiver
issues, resource allocation concerns and much
more.
The dissenting judge in the legal case argued that
the court should have used the condition
anencephaly as the basis of the case, not the
recurring subsidiary symptoms of respiratory
distress. As the irreversibility of anencephaly is
highly accepted in the medical community, he
argued that the decision to continue (futile) care
only resulted in irresponsible use of medical
resources, and prolonged suffering.