- Orit Navot, R.N., B.A.
The Jakobovits Centre for Jewish Medical Ethics, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
There are many discussions these days about the ethical right to make decisions with respect to the care of premature infants. As was reported in the October 1993 issue of HaAhot b'Israel (The Israeli Nurse), the care for an infant born prematurely at the 24th week of pregnancy costs about US$100,000. In a country where the national budget is highly limited by the costs of defense and of the absorption of Jewish immigrants from all over the world, this is a substantial expense which raises many social questions. From this situation many ethical issues arise. The nurse in a neonate intensive care unit is an integral part of an advanced medical system in which many resources are invested. This medical system must provide solutions to medical and social questions which were unknown to past generations.
With the help of advanced technology, medical advances, modern midwifery, new approaches to neonatal care, and with the impetus of the belief in the right to live - the boundaries of life have expanded far beyond what we once could of dreamt of. These factors have lead to the sharpening of the question: where and when may we decide to limit our active intervention with the course of nature? And who has the right to make such decisions? In the field of intensive care for premature infants, all members of the team are highly active in care and in decision-making. The nurse working at the intensive care station is frequently exposed to emotional outbursts on the art of the parents, as well as to the feelings of the various members of the team. This complex emotional situation arises from our inability to predict what precisely will be the results of medical intervention: does modern neonate medicine produce disabled lives and heavy burdens for families and for society? Or is neonate intensive care a genuine medical advance which promises health and happiness? Just as it is often impossible to know exactly what is the right course of action, it is also difficult to know whether moral decisions should be determined by written, authorised guidelines, or whether it is best to rely on the conscience of professionally well-trained and well-intentioned experienced individuals. When our relationship to the individual patient is dictated by guidelines, then we may end up treating the patient no as an end in their self but as a mere means to the end of fulfilling the guidelines. If we are to allow ethical decisions to be determined by guidelines then we must ask: who has the authority to determine the guidelines? And we must be sure there are no conflicts among the various guidelines.
Unlike the competent mature patient the premature cannot make his opinions known and others put themselves forward as his spokesperson. Both opponents of heroic measures to sustain life, and those in favour of such measures see themselves as morally obligated to influence the situation. The nurse's involvement in neonate intensive care decision-making also leads to her involvement in the difficult and doubtful questions. Her job is by no means simply to obey the physician's orders but to take active part in the ethical thinking. As a full member if the team, her voice is heard and has its effect on ethical decision-making.