Selective treatment of irreversibly impaired infants: Decision-making at the threshold

Medical Law Review

Volumn 17, Issue 3, 2009, Pages 347-376

  Morris, Anne ^a  

^a UNIVERSITY OF LIVERPOOL   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONGENITAL DISORDER; DECISION MAKING; ETHICS; HEALTH CARE POLICY; HUMAN; HUMAN RELATION; INFANT; LEGAL ASPECT; MEDICAL ETHICS; MORTALITY; NEWBORN; PERSISTENT VEGETATIVE STATE; PREMATURITY; PROFESSIONAL PRACTICE; QUALITY OF LIFE; TREATMENT WITHDRAWAL; UNITED KINGDOM;

CONGENITAL ABNORMALITIES; DECISION MAKING; ETHICS, MEDICAL; GREAT BRITAIN; HEALTH POLICY; HUMANS; INFANT; INFANT, NEWBORN; INFANT, PREMATURE; PERSISTENT VEGETATIVE STATE; PROFESSIONAL AUTONOMY; PROFESSIONAL-PATIENT RELATIONS; QUALITY OF LIFE; WITHHOLDING TREATMENT;

EID: 70449356966     PISSN: 09670742     EISSN: 14643790     Source Type: Journal    
DOI: 10.1093/medlaw/fwp017     Document Type: Article

References (205)

1. http://www.nuffieldbioethics.org/go/ourwork/neonatal/ publication_406.html, hereafter 'Nuffield'.
2. Re Wyatt (a child) (medical treatment: Parents' consent) [2004] EWHC 2247, (Fam); Re Wyatt (a child) (medical treatment: Continuation of order) [2005] EWHC 2293, (Fam), [2006] Fam 188; [2005] EWCA Civ. 1181, [2005] 1 WLR 3995; Re Wyatt (No 3) (a child) (medical treatment: Parents' consent) [2005] EWHC 693, (Fam), [2005] 2 FLR 480; Re Wyatt [2006] EWHC 319 (Fam), [2006] 2 F.L.R. 111; Re Wyatt (a child) (medical treatment: Continuation of order) [2005] EWCA Civ 1181, [2005] 1 WLR 3995. Most internet contributions were staunchly 'pro-life'.
3. See also the dispute in relation to Luke Winston-Jones: Re L (Medical Treatment: Benefit) [2004] EWHC 2713 (Fam).
4. The term 'disabled' is challenged by those who argue that it is society which 'dis-ables' those who have impairments: E.g., A Asch, 'Difference and the Delivery of Health Care' (1998) 7 Cambridge Quarterly of Heathcare Ethics 77.
5. See also Nuffield, 3.29-3.31.
6. See, e.g., M Brazier and E Cave, Medicine, Patients and the Law (Penguin, London 2007)
7. S Sheldon, 'Rethinking the Bolam Test', in S Sheldon and M Thompson (eds) Feminist Perspectives on Health Care Law (Cavendish, London 1998)
8. J Montgomery, 'Medicine, Accountability and Professionalism' (1989) 16 Journal of Law and Society 319, and 'Law and the Demoralisation of Medicine' (2006) 26 Legal Studies 185
9. The Right Honourable, the Lord Woolf, 'Are the Courts Excessively Deferential to the Medical Profession?' (2001) 9 Med L Rev 1.
10. C.f. R v Arthur, 12 BMLR 1 (1981) and below.
11. V Harpwood, 'The Manipulation of Medical Practice', in M Freeman and ADE Lewis (eds), Law and Medicine, Current Legal Issues (vol 3 OUP, Oxford 2000) 47, 59.
12. See further below and R (on the application of Burke) v The General Medical Council [2005] EWCA Civ 1003, [2006] QB 273, [55].
13. I Kennedy, The Unmasking of Medicine (Ch. 4 Allen and Unwin, London 1981).
14. As in Re L and Re Wyatt respectively, above n 2.
15. CEMACH, Stillbirth, Neonatal and Post-Natal Mortality 2000-2003, England, Wales and Northern Ireland, London (RCOG Press, London 2005).
16. DJ Wilkinson and others, 'Death in the Neonatal Intensive Care Unit: Changing Patterns of End of Life Treatment Over Two Decades' (2006) Arch Dis Child, Fetal and Neonatal Edition F268; R v Arthur (1981) 12 BMLR 1 and below.
17. Inluding, e.g., severe respiratory distress syndrome, cerebral haemorrhage and necrotising enterocolitis.
18. K Costeloe and others, 'The EPICure Study: Outcomes to Discharge from Hospital for Infants Born at the Threshold of Viability' (2000) 106 Pediatrics 659-71
19. T Markestad, 'Early Death, Morbidity, and Need of Treatment among Extremely Premature Infants' (2005) 115 Pediatrics 1289-98
20. J Mursakas and others, 'Neonatal Viability in the 1990s: Held Hostage by Technology', in M Freeman, Children, Medicine and the Law (Aldershot, Ashgate 2005)
21. N Marlow, 'Neurocognitive Outcome after Very Preterm Birth' (2004) 89 Arch Dis Child Fetal Neonatal Edition F224.
22. Above n 1.
23. Nuffield, 9.16. The Report suggests accuracy of assessing gestational age has improved: 5.4, but it is not 100% precise.
24. See, e.g., RD Higgins and others, 'Executive Summary of theWorkshop on the Border of Viability' (2005) 115 Pediatrics 1392
25. Costeloe, above n 13.
26. See below for a discussion of 'futility.'
27. Nuffield, 9.17.
28. Nuffield, 9.32-34.
29. See below, Holman J in An NHS Trust v B [2006] EWHC 507 (Fam), [2006] 2 FLR 319.
30. Nuffield, 8.56-8.62; 8.48-8.51.
31. See further below 'Alternatives to best interests'.
32. Re B (a minor) (wardship: Medical treatment) [1982] 3 FLR 117.
33. R v Arthur (1981) 12 BMLR 1.
34. J Read and L Clements, 'Demonstrably Awful: The Right to Life and the Selective Non-Treatment of Disabled Babies and Young Children' (2004) 31 Journal of Law and Society 482, 483.
35. RS Duff and AGM Campbell, 'Moral and Ethical Dilemmas in the Special-Care Nursery' (1973) 289 N Engl J Med 890-94.
36. See for an account of this, H Kuhse and P Singer, 'Should the Baby Live: The Problem of Handicapped Infants' (Ch 3 OUP, Oxford 1985).
37. Ibid., p 49.
38. See also I Kennedy, The Unmasking of Medicine (Allen & Unwin, London 1981) 82, noting that when active intervention was introduced, the number of 'stillbirths' fell.
39. Ibid., at p 18.
40. See also Airedale National Health Service Trust v Bland [1993] AC 789, 880, per Lord Browne-Wilkinson: 'In the past, doctors exercised their own discretion, in accordance with medical ethics, in cases such as these. To the great advantage of society, they took the responsibility of deciding whether the perpetuation of life was pointless'.
41. I Kennedy, Treat Me Right (OUP, Oxford 1988) 157-58.
42. [1982] 3 FLR 117, at 122.
43. J Montgomery, 'Time for a Paradigm Shift? Medical Law in Transition', in Freeman (ed.) Current Legal Problems (OUP, Oxford 2000) 363.
44. I Kennedy, The Unmasking of Medicine (Allen & Unwin, London 1981) 80-83.
45. [1982] 3 F.L.R. 117.
46. [1991] Fam 33.
47. [1993] Fam 15.
48. Ibid., p 41. Emphasis added.
49. Ibid.
50. See also Re R [1992] Fam 11.
51. [1993] Fam 15.
52. Ibid, at p 27. Even if, in theory, another doctor could be found who would be prepared to treat, there might be insurmountable logistical problems in transferring the patient's care: [1993] Fam 15, per Lord Donaldson.
53. See also Wyatt [2005] EWHC 117 (Fam), [18], per Hedley J.
54. As exemplified in Re A (Children) (Conjoined twins) [2001] Fam 147.
55. R Lee and D Morgan, 'Regulating Risk Society: Stigmata Cases, Scientific Citizenship and Biomedical Diplomacy' (2001) 23 Sydney Law Review 297. They include Airedale National Health Service Trust v Bland [1993] AC 789
56. and In Re A (Children) (Conjoined twins: Surgical separation) [2001] Fam 147.
57. NHS Trust v B [2006] EWHC 507 (Fam), [2006] 2 F.L.R. 319, per Holman J at [24]. Emphasis added.
58. See also Re C (a minor) (wardship: Medical treatment) [1990] Fam 26.
59. Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice, 2nd Ed. RCPCH, 2004.
60. See also BMA Guidelines, Withholding and Withdrawing Life-Prolonging Medical Treatment: Guidance for Decision Making (2nd edn BMJ Books, London 2001).
61. Although there are difficulties in diagnosing brain stem death in neonates: Ibid., p 10
62. Nuffield, p 190.
63. Above, n 43, p 8.
64. See, e.g., Re C (a minor) (medical treatment) [1998] 1 FLR 384, [1998] Fam Law 135, 40 BMLR 31.
65. Although an anencephalic infant in the USA survived for 2 1/2 years: Baby K 16 F.3d 590 CA 4 (Va.), 1994.
66. Re L (medical treatment: Benefit) [2004] EWHC 2713 (Fam), [2005] 1 FLR 491.
67. It is unclear whether complications of extreme prematurity or low birth weight would count as an 'abnormality'.
68. Re T (a minor)(wardship: Medical treatment) [1997] 1 All ER 906.
69. M Fox and J McHale, 'In Whose Best Interests?' (1997) 60 MLR 700; A Bainham, 'Do Babies Have Rights?' (1997) 56 CLJ 48.
70. Re Wyatt (a child) (medical treatment: Parents' consent) [2004] EWHC 2247 (Fam) [15].
71. ED Pellegrino, 'Futility in Medical Decisions: The Word and the Concept' (2005) 17 HEC Forum 308.
72. Ibid., 309.
73. Airedale National Health Service Trust v Bland [1993] AC 789.
74. Ibid., e.g., Lord Goff at p 858, Lord Lowry at p 876. Compare J Keown, 'Beyond Bland: A Critique of the BMA Guidance on Withholding and Withdrawing Medical Treatment' (2000) 20 Legal Studies 66.
75. J Keown, 'A Futile Defence of Bland: A Reply to Andrew McGee' (2005) 31 Med L Rev 393.
76. Airedale National Health Service Trust v Bland [1993] AC 789 at p 869, per Lord Goff: '...the condition of the patient...is such that life-prolonging treatment is properly regarded as being, in medical terms, useless....I cannot see that medical treatment is appropriate or requisite simply to prolong a patient's life when such treatment has no therapeutic purpose of any kind, as where it is futile because the patient is unconscious and there is no prospect of any improvement in his condition'.
77. See E Gampel, 'Does Professional Autonomy Protect Medical Futility Judgments?' (2006) 20 Bioethics 92, at 94
78. DP Sulmasy, 'Futility and the Varieties of Medical Judgment' (1997) 18 Theoretical Medicine 63, at 64.
79. Gampel, ibid., supra at 95-96.
80. In re F (Mental Patient: Sterilisation) [1990] 2 AC 1, Airedale NHS Trust v Bland [1993] AC 789, 884.
81. [2000] 1 FLR 549.
82. Ibid at 555(e).
83. See also Re S (Sterilisation: Best interests) [2001] Fam 15
84. In Re L (medical treatment: Benefit) [2004] EWHC 2713 (Fam), [2005] 1 FLR 491.
85. Re S above distinguishing the test for negligence laid down in Bolam v Friern Hospital Management Committee [1957 [2 All E.R. 118.
86. See also R (on the application of N) v Dr M and others [2002] EWCA Civ 1789.
87. Re J [1991] Fam 33, 46-47.
88. In re C (a minor) (wardship: Medical treatment) [1990] Fam 26.
89. Ibid., at p 35.
90. See, e.g., Taylor LJ in Re J [1991] Fam 33 at 55
91. A National Health Service Trust v D [2000] Fam Law 803, [2000] 2 FLR 677, and see below.
92. Re J [1991] Fam 33.
93. Ibid., at p 51.
94. Balcombe LJ also observed that Re B had not sought to lay down a test applicable to all circumstances since facts were so varied: P 52.
95. P Boddington and T Podpadec, 'Measuring Quality of Life in Theory and Practice', in H Kuhse and P Singer (eds) Bioethics: An Anthology (Blackwell, Oxford 1999).
96. As with a persistent vegetative state, per Lord Mustill in Bland [1993] 1 AC 789, 897.
97. But c.f. Hoffmann LJ, ibid., 829.
98. D Wilkinson, 'Is It in the Best Interests of an Intellectually Disabled Infant to Die?' (2006) 32 J Med Ethics 454.
99. Ibid.
100. HE McHaffie and others, 'Deciding for Imperilled Newborns: Medical Authority or Parental Autonomy?' (2001) 27 Journal of Medical Ethics 104-9.
101. See, e.g., Re J (a minor)(wardship: Medical treatment) [1991] Fam 33, per Lord Donaldson at 934.
102. Disability remains a barrier to equal access to social goods including education and health care. See, e.g., An NHS Trust v S [2003] EWHC 365, 71 BMLR 188
103. Joseph Rowntree Foundation, Supporting Disabled Children and their Families (Joseph Rowntree Foundation, York 1999).
104. J Hardwig, 'What about the Family?' (1990) 20 Hastings Center Report 5. C.f. Abortion Act 1967, s. 1(1)(a), which allows for termination of pregnancy where continuing is a risk to the mental or physical health of the mother or any existing children.
105. J Herring, 'Where Are the Carers in Healthcare Law and Ethics?' (2006) 27 Legal Studies 51, 65.
106. Ibid.
107. RM Hare, 'The Abnormal Child: Moral Dilemmas of Doctors and Parents' in H Kuhse and P Singer (eds) Bioethics: An Anthology, (Blackwell, Oxford 1999) 271.
108. DL Streiner and others, 'Attitudes of Parents and Health Care Professionals toward Active Treatment of Extremely Premature Infants' (2006) Pediatrics 118-152; this study found evidence that the socio-economic standing of the family did not influence decisions, but that the potential stress that the family would experience was a factor.
109. See, e.g., Airedale National Health Service Trust v Bland [1993] AC 789, per Lord Goff, 871
110. Re G [1995] 2 FCR 46. C.f. Re Y (Mental patient: Bone marrow donation) [1997] Fam 110, 35 BMLR 111: In the interests of incapacitated adult to donate bone marrow because of the impact on the family.
111. See also K O'Donovan and R Gilbar, 'The Loved Ones: Families, Intimates and Patient Autonomy' (2003) 23 Legal Studies 332.
112. See, e.g., HE McHaffie and others, 'Deciding for Imperilled Newborns: Medical Authority or Parental Autonomy?' (2001) 27 JME 104-9, 107.
113. See also: [2004] OWHC 2247 [18]: one of the doctors caring for Charlotte Wyatt would have considered a tracheotomy, partly in order 'to accommodate parental views and to give them more time and information in order to come to terms with the advice that they were receiving'.
114. France is the exception: M Cuttini and others, 'Parental Visiting, Communication and Participation in Ethical Decisions: A Comparison of Neonatal Unit Policies in Europe' (1999) 81 Arch Dis Child Fetal Neonatal Ed F84.
115. Ibid.
116. HE McHaffie and others, 'Deciding for Imperilled Newborns: Medical Authority or Parental Autonomy?' (2001) 27 Journal of Medical Ethics 104.
117. Ibid, p 105.
118. Ibid.
119. Ibid, p 107.
120. Streiner, above n 82.
121. Above n 87, 106.
122. See C Heimer, 'Competing Institutions: Law, Medicine and Family in Neonatal Intensive Care', (1999) 33 Law & Society Review 17, 29-30.
123. E Friedson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (Harper & Row, New York 1970) 187.
124. Ibid, 360.
125. O O'Neill, A Question of Trust (Cambridge University Press, Cambridge 2002).
126. Royal College of Mhysicians: Doctors in society: medical professionalism in a changing world, Report of a Working Party of the Royal College of Physicians of London, (2005) RCP, London, Para 1.13.
127. V Harpwood, 'The Manipulation of Medical Practice', in M Freeman and ADE Lewis (eds), Law and Medicine, Current Legal Issues (vol 3 OUP, Oxford 2000) 47.
128. In a different context, see M Mulcahy, 'Threatening Behaviour? The Challenge Posed by Medical Negligence Claims', in M Freeman and ADE Lewis (eds), Law and Medicine, Current Legal Issues (vol 3 OUP, Oxford 2000) 81.
129. HE McHaffie and others, Crucial Decisions at the Beginning of Life (Radcliffe Medical Press, Oxford 2001); Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice (2nd edn RCPCH, Oxford 2004).
130. M Rebagliato and others, 'Neonatal End of Life Decision Making: Physicians' Attitudes and Relationship with Self-reported Practices in 10 European Countries' (2000) 284 JAMA 2451.
131. Ibid., Table 2.
132. Ibid.
133. M Cuttini and others, 'End-of-life Decisions in Neonatal Intensive Care: Physicians' Self-reported Practices in Seven European Countries' (2000) 355 The Lancet 2112.
134. R Veatch, 'Abandoning Informed Consent' (1995) 12 Hastings Center Report 5, cited in J Savulescu, 'Liberal Rationalism and Medical Decision-making' (1997) 11 Bioethics 115.
135. Re C (a minor) (medical treatment) [1998] 1 FLR 384, [1998] Fam Law 135, 40 BMLR 31.
136. Cuttini, above n 104. See also Rebagliato, above n 101.
137. K Kovach, 'Neonatology Life and Death Decisions: Can Mediation Help?' (2000) 28 Capital University Law Review 251.
138. HE McHaffie and others, 'Deciding for Imperilled Newborns: Medical Authority or Parental Autonomy?' (2001) 27 Journal of Medical Ethics 104.
139. Ibid., 107.
140. Ibid.
141. Ibid.
142. M Cuttini and others, 'Parental Visiting, Communication and Participation in Ethical Decisions: A Comparison of Neonatal Unit Policies in Europe' (1999) 81 Arch Dis Child Fetal Neonatal Ed F84.
143. RWI Cooke, 'Good Practice in Consent' (2005) 10 Seminars in Fetal and Neonatal Medicine 63.
144. McHaffie, above n 109; J Tripp and D McGregor 'Withholding and Withdrawing of Life Sustaining Treatment in the Newborn' (2006) 91 Archives of Disease in Childhood, Fetal and Neonatal Edition F67-F71.
145. See Glass and another v United Kingdom (App no 61827/00) [2004] 1 FCR 553, [2004] Fam Law 410.
146. See, e.g., Re C (a minor) (medical treatment) [1998] 1 FLR 384, [1998] Fam Law 135.
147. In An NHS Trust v B [2006] EWHC 507 (Fam); [2006] 2 FLR 319, the mother believed, erroneously, that a treatment might soon be discovered to cure her son: [47].
148. See also Royal Wolverhampton Hospitals NHS Trust v B [2000] 2 FCR 76.
149. A National Health Service Trust v D [2000] Fam Law 803, [2000] 2 FLR 677.
150. It may also throw light on a perceived hierarchy of medical expertise as between doctors and nurses: M Coombs and SJ Ersser, 'Medical Hegemony in Decision-making - a Barrier to Interdisciplinary Working in Intensive Care?' (2004) 46 Journal of Advanced Nursing 245.
151. Heimer, above n 93, notes that only certain people are authorised to make medical notes - not parents.
152. Cazalet J likened the case to Re J [1991] FCR 370, Fam 33, above n 33, which had 'some factual similarity to the instant case'. This is surprising as J was probably without sight, speech, or hearing, and his only likely normal reaction was that of pain.
153. Re Wyatt (a child) (medical treatment: Parents' consent) [2004] EWHC 2247 (Fam), [2005] 1 FLR 21.
154. [2005] EWHC 693 (Fam), [2005] 2 FLR 480, [5].
155. Re Wyatt (a child) (medical treatment: Continuation of order) [2005] EWCA Civ 1181, [2005]. The case returned to Hedley J in October 2005: Re Wyatt (a child) (medicalCtreatment: continuation of order) [2005] EWHC 2293 (Fam). Hedley J concluded that in the light of further improvements a declaration would not be granted, but reassured doctors that parental wishes should be accommodated only as far as professional judgment and conscience would permit: [41].
156. Re L (Medical Treatment: Benefit) [2004] EWHC 2713 (Fam).
157. [2000] 1 FLR 549, at 555(e).
158. [2006] EWHC 507 (Fam).
159. [2005] EWHC 693 (Fam) [5].
160. Above (n 128) [100].
161. See also Re L (Medical Treatment: Benefit) [2004] EWHC 2713 (Fam) [30] in which Butler-Sloss P expressed herself 'uneasy' at the idea that cardiac massage should be excluded.
162. See also Re Wyatt (a child) (medical treatment: Parents' consent) [2004] EWHC 2247 (Fam) [41], where Hedley J commented that he 'would like to ask the treating doctors (without in any way suggesting an answer to them) to give further consideration to an elective tracheostomy'.
163. If the duty is to act in the best interests of the patient, and that means prolonging life, then the withdrawal of life support would be a culpable omission: Airedale National Health Service Trust v Bland [1993] AC 789.
164. Nuffield 2.53.
165. N Rhoden, 'Treating Baby Doe: The Ethics of Uncertainty' (1986) 16(A) Hastings Center Report 34
166. J Muraskas and others, 'Neonatal Viability in the 1990s: Held Hostage by Technology', (1999) 8 Cambridge Quarterly Healthcare Ethics 160-72
167. ML Gross, 'Abortion and Neonaticide: Ethics, Practice and Policy in Four Nations' (2002) 16 Bioethics 202.
168. 'Guidelines on Forgoing Life-sustaining Medical Treatment' (1994) 93 Pediatrics 532.
169. Ibid. For a judicial discussion of 'best interests', see In re Christopher I (2003) 106 Cal. App. 4th 533.
170. See H Kuhse and P Singer, 'Should the Baby Live: The Problem of Handicapped Infants' (OUP, Oxford 1985) 21 et seq;
171. FI Clark, 'Withdrawal of Life Support in the Newborn: Whose Baby Is It?', (1993) 23 Sw. UL Rev 1.
172. LM Kopelman and others, 'Neonatologists Judge the Baby Doe Regulations' (1988) 318 New Eng J Med 677
173. LM Kopelman, 'Are the 21-Year-Old Baby Doe Rules Misunderstood or Mistaken?' (2005) 115 Pediatrics 797
174. M Rebagliato and others, 'Neonatal End of Life Decision Making' (2000) 284 JAMA 2451.
175. Ibid., citing JD Lantos and others, 'Withholding and Withdrawing Life Sustaining Treatment in Neonatal Intensive Care: Issues for the 1990s' (1994) 71 Arch Dis Child Fetal Neonatal Ed. F218.
176. JA Robertson, 'Extreme Prematurity and Parental Rights after Baby Doe' (2004) 4 Hastings Center Report 34, 32
177. Kopelman, above n 138.
178. See the Messenger case: JJ Paris, 'Parental Right to Determine Whether to Use Aggressive Treatment for an Early Gestational Age Infant: the Messenger Case' (1997) 16 Med & L 679.
179. See also Miller v HCA 47 Tex Sup.J 12, 118 S.W. 3d 758 (2003).
180. See GJ Annas, 'Extremely Pre-Term Birth and Parental Authority to Refuse Treatment - The Case of Sidney Miller' (2004) 351 N Engl J Med 2118.
181. Matter of Baby K 16 F.3d 590 C.A.4 (Va.), 1994. See Berger and others, 'Medical Futility: Towards Consensus on Disagreement' (1998) 10 HEC 102.
182. See, e.g., Montalvo v Borkovec 647 NW2d 413 (2002): Neonatologist not required to inform parents of the option to withhold or withdraw life-sustaining medical treatment (at 23 weeks' gestation). Court held, inter alia, that '...a State may properly decline to make judgments about the 'quality' of life that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual'.
183. JA Robertson, 'Extreme Prematurity and Parental Rights after Baby Doe' (2004) 4 Hastings Center Report 32.
184. See also Canadian Paediatric Society, Society of Obstetricians and Gynaecologists of Canada: 'Management of the Woman with Threatened Birth of an Infant of Extremely Low Gestational Age' (1994) 151 Canadian Medical Association Journal 547, http://www.cps.ca/english/statements/fn/ fn94-01.htm.
185. Danish Council of Ethics, Debate Outline: Extreme Prematurity, Ethical Aspects (Eurolingua, Copenhagen 1995). What follows is taken from ML Gross, Abortion and Neonaticide: Ethics, Practice and Policy in Four Nations (2002) 16 Bioethics 202.
186. JB van Goudoever, 'Treatment Decisions at the Threshold of Viability' (2006) 2 Eur Clinics Obstet Gynaecol 82.
187. C.f. R v Arthur 12 BMLR 1.
188. E Verhagen and PJJ Sauer, 'The Groningen Protocol - Euthanasia in Severely Ill Newborns' (2005) 352 New Eng J Med 959.
189. 'Response of the Ethics Committee of the Royal College of Obstetricians and Gynaecologists to the Nuffield Council on Bioethics consultation document "The ethics of prolonging life in fetuses and the newborn"' (2005) RCOG, p 8.
190. Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues (Nuffield Council on Bioethics, London 2006) 2.37.
191. NN Dubler and CB Liebman, Bioethics Mediation: A Guide to Shaping Shared Solutions (United Hospital Fund, NY 2004).
192. Nuffield, 8.57.
193. Ibid., 8.62.
194. K Kovach, 'Neonatology Life and Death Decisions: Can Mediation Help?' (2000) Cap. UL Rev. 251, 283.
195. See Re S (Sterilisation: Best interests) [2001] Fam 15.
196. J Slomka, 'Clinical Ethics and the Culture of Conflict' (2005) 35 Hastings Center Report 45.
197. For a general discussion, see http://www.ethox.org.uk/reading/Guide/ Guide.htm.
198. American Academy of Pediatrics: Institutional Ethics Committees, (2001) 107 Pediatrics 205.
199. Royal College of Physicians, Ethics in Practice: Background and Recommendations for Enhanced Support (RCP, London 2005).
200. Re Wyatt (a child) (medical treatment: Parents' consent) [2004] EWHC 2247 (Fam) [4].
201. Nuffield 8.52.
202. J Harris, 'Human Beings, Persons and Conjoined Twins: An Ethical Analysis of the Judgment in Re A (2001) 9 Med L Rev 221.
203. C.f. Munby J in R (Burke) v GMC [2004] EWHC 1879 (Admin), [2004] 3 FCR 579, [2005] QB 424, 'the touchstone of best interests in this context is intolerability', at [111].
204. Nuffield 2.16.
205. TK Bastek and others, 'Prenatal Consultation Practices at the Border of Viability: A Regional Survey' (2005) 116 Pediatrics 407, at 412.