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consent. Next, we review approaches to conflicts between the autonomy of the pregnant woman and her obligations of beneficence toward the fetus. We then present the current attitudes and practices with respect to the limits of viability.

Next, we present the literature related to ethical issues in end-of-life care, including the practice of withholding or withdrawing life-sustaining medical treatments, pain control and palliative care, the concept of futility, and the differences in end-of-life practices between U.S. physicians and physicians in some parts of Europe. We then examine the literature concerning the economic and social implications of premature birth. Finally, we comment on the inclusion of pregnant women, fetuses, and neonates in research.

ETHICAL ASPECTS OF DECISION MAKING

The predominant ethical paradigm for decision making about the early stages of reproduction (i.e., preventing pregnancy, becoming pregnant, deciding to stay pregnant, and engaging in activities that may help or harm a fetus) focuses on the autonomy of the woman. A transition occurs in midpregnancy, wherein the emphasis on a woman’s autonomy is weakened in favor of balancing fetal and maternal “best interests.” For some, this shift may be viewed as occurring when either the choice or the opportunity for termination of the pregnancy has passed. This time of transition during pregnancy from a previable to a viable fetus (i.e., 23 to 25 weeks of gestation) can also be viewed as an ethical (and perhaps legal) transition from an individual autonomy-based model of decision making to a negotiated beneficence-based model of decision making. This view, although useful, is perhaps an oversimplification, as fetal interests are often important factors early in pregnancy and maternal autonomy remains influential during the late stages of pregnancy.

The paradigm (in the United States and most Western countries) for proxy decision making for infants and children focuses on a child’s “best interest,” with the parents or guardians generally viewed as the primary surrogate decision makers for their infants. However, health care professionals play an important role in determining what actions are, in fact, in a child’s best interest, leading to a more complex “negotiated” decision-making process. Ethical dilemmas may arise when parents and the medical professionals caring for their infants disagree on the best course of action.

Empirical Data Concerning Proxy Decision Making

Parents largely believe that they do and should take primary responsibility for decisions concerning the limitation or withdrawal of life-sustaining medical treatment (LSMT) from their critically ill infants. The majority



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