Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978-2017

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in-person, semi-structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision-making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.