Navigating parental disagreement: ethical analysis and a proposed approach

Area of Science:

• Pediatric Ethics
• Neonatal Resuscitation
• Shared Decision-Making

Background:

• Disagreements in pediatric shared decision-making pose challenges, particularly when parents conflict.
• Existing frameworks like impermissible-permissible-obligatory (I-P-O) address clinician-parent disagreements but lack guidance for parental discordance.
• Critical clinical decisions, such as neonatal resuscitation, are complex when parents have opposing views.

Purpose of the Study:

• To analyze approaches for clinical decision-making when parents disagree on pediatric care.
• To propose an expanded impermissible-permissible-obligatory (I-P-O) framework to address parental discordance in critical pediatric situations.
• To provide ethical guidance for delivery room care in cases of parental disagreement.

Main Methods:

• Analysis of a clinical case involving parental disagreement over resuscitation for a borderline gestational age neonate.
• Evaluation of four potential approaches to delivery room care based on ethical principles.
• Proposal for an expanded I-P-O framework incorporating clinical details, patient best interests, and parental values.

Main Results:

• Four options for delivery room care were identified: deferring to the pregnant parent, requiring consensus, proceeding with either parent's request, or using an advisability framework.
• Each approach presents distinct merits and flaws regarding parental authority and patient welfare.
• The proposed expanded I-P-O framework offers a structured method for navigating parental discordance.

Conclusions:

• Parental disagreement in pediatric decision-making requires specific ethical strategies.
• An expanded I-P-O framework, considering clinical advisability, best interests, and values, can guide clinicians facing parental discordance.
• This framework aims to optimize decision-making for neonates in complex ethical situations.