Parental manual ventilation in resource-limited settings: an ethical controversy
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Published on: March 12, 2018
Emily Barsky1,2, Sadath Sayeed3,4
1Division of Pulmonary Medicine, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA emily.barsky@childrens.harvard.edu.
Insights
In low-income countries, hand-bag ventilation by parents can be a life-saving measure for children with respiratory failure when mechanical ventilators are unavailable. This approach presents ethical challenges, but a structured method for parental involvement is proposed.
Area of Science:
- Pediatric critical care
- Bioethics
- Global health
Background:
- Lower respiratory tract infections are a major cause of child mortality globally, particularly in low-income countries due to limited healthcare resources.
- Mechanical ventilation is crucial for treating acute respiratory failure in children, but its scarcity in resource-limited settings leads to preventable deaths.
- Hand-bag ventilation, where family members manually assist ventilation, is used as a temporary measure but raises significant ethical concerns.
Purpose of the Study:
- To examine the ethical considerations surrounding parental hand-bag ventilation for children with respiratory failure in low-income countries.
- To explore arguments for and against parental involvement in manual ventilation.
- To propose an ethically guided framework for parental participation in manual ventilation.
Main Methods:
- Review of existing literature on mechanical ventilation, hand-bag ventilation, and pediatric respiratory infections in resource-limited settings.
- Analysis of ethical arguments including the best interests of the child, right to an open future, beneficence, parental protection, and concerns about substandard care.
- Development of an algorithmic approach to potentially permit parental participation in manual ventilation.
Main Results:
- Parental hand-bag ventilation is a practice employed in situations of extreme resource scarcity.
- Ethical debates involve balancing the child's well-being and right to an open future against the benefits of immediate life support and parental roles.
- Contextual factors significantly influence the ethical permissibility of this intervention.
Conclusions:
- Parental hand-bag ventilation is a complex intervention with profound ethical implications in resource-limited settings.
- A nuanced ethical analysis is required, considering various ethical principles and contextual realities.
- An algorithmic approach may offer a pathway to ethically permissible parental involvement in manual ventilation, prioritizing the child's best interests.
Abstract:
Lower respiratory tract infections are a leading cause of paediatric morbidity and mortality worldwide. Children in low-income countries are disproportionately affected. This is in large part due to limitations in healthcare resources and medical technologies. Mechanical ventilation can be a life-saving therapy for many children with acute respiratory failure. The scarcity of functioning ventilators in low-income countries results in countless preventable deaths. Some hospitals have attempted to adapt to this scarcity by using hand-bag ventilation, as either a bridge to a mechanical ventilator, or until clinical improvement occurs rendering mechanical ventilation no longer necessary. In instances of hand-bag ventilation, an endotracheal tube is first placed. Family members are then asked to play the role of a ventilator, manually compressing a bag repeatedly to inflate the child's lungs. This approach is fraught with numerous ethical challenges. A careful examination of the data and a nuanced approach to the ethical considerations are imperative. Ethical arguments in support of and in opposition to allowing parental hand-bag ventilation are explored, including the best interests of the child, the child's right to an open future, beneficence and parental protection, legitimising substandard care, and finally, contextual concerns. An algorithmic, potentially ethically permissible approach to parental participation in manual ventilation is proposed.
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