A LEGAL FRAMEWORK FOR EOLC IN BABIES AND CHILDREN -PERSPECTIVES ROY JOSEPH EMAIL: PAEROYJ@NUS.EDU.SG YONG LOO LIN SCHOOL OF MEDICINE, PAEDIATRIC ETHICS AND ADVOCACY CENTER
BABY OF LEAH Madam Leah at 25 weeks pregnancy with chorio-amnionitis • Delivery is imminent • The Neonatologist cites a 80% survival rate and rates of 30%, 20% and 10% • respectively in survivors for the following long term outcomes - mild disability, moderate and, severe disability. A hospital stay of about 3.5 months and charges of about S$136,000 are to be expected.
BABY OF LEAH Madam Leah at 25 weeks pregnancy with chorio-amnionitis • The Dr considers these outcome rates as being highly favorable • and advocates that the baby be intensively treated as that is in the baby’s best interest.
PARENTS POSITION • Parents after about an hour communicate their unanimity that the odds are stacked against the baby and intensive care will not be in the baby’s best interest; hence only comfort care is to be provided and that natural demise be allowed to take place;
PARENTS POSITION • This is because with interventions the likelihood of death-(20%) or moderate or greater disability is very high (34% of survivors); this is not good for the child in the future in this highly competitive society.
DOCTORS RESPONSE ( SCENARIO 1 ) • Doctor disagrees and seeks to save life with intensive care and insists that parents agree to allow intensive care to be started upon delivery. • Parents claim their rights as parents to decide what is best for their child. • The doctor says her duty to act in the child’s best interest trumps the parents rights and issues orders to begin intensive care from birth.
TREATING WITHOUT CONSENT • About an hour later , baby Leah is born with a weight of 600 grams and features consistent with a 25 week gestation. She is unable to sustain her respirations and positive pressure ventilation through an endo tracheal tube is begun soon after. Shortly after being shown to the parents, she is transferred to the intensive care unit.
REACTIONS • The father telephones the family lawyer for advice and assistance • The doctor makes a call to the Ethics consultant and prepares to call the Hospital’s legal counsel next.
DOCTORS RESPONSE ( SCENARIO 2 ) • Parents are apprehensive that the doctor is not prepared to commit and fear that by the time certainty is obtained, the likelihood of a natural and good death would have passed and they will be faced with the prospects of having to observe the baby being nursed to a slow and painful death or face the prospects of not seeing their child grow to an independent and productive life. This they say cant be in the child’s best interests and will cause harm to the family.
DOCTORS RESPONSE ( SCENARIO 2 ) • Doctor acknowledges the risks are high and suggests that intensive care be started at delivery but with the assurance that recommendations for the withdrawal of intensive care and replacement with comfort care will be made whenever complications that increase the certainty of moderate or severe disabilities develop. However when pressed is reluctant to commit to what these complications and the thresholds of risks are .
DOCTORS RESPONSE ( SCENARIO 2 ) • They claim their rights as parents to decide what is best for their child. • The doctor says her duty to act in the child’s best interest trumps the parents rights and issues orders to begin intensive care when the baby is born.
REACTIONS (2) • The father telephones the family lawyer for advice and assistance • The doctor makes call to the Ethics consultant and prepares to call the Hospital’s legal counsel next
ALTERNATE SCENARIO (3) • How will/should the doctor’s response change if Parents share that their 3 year old has global developmental delay and cerebral palsy after a premature birth; they cant take the risk of having another baby with special needs ?
ALTERNATE SCENARIO (4) • How will/should the doctor’s response change if If the mother turns out to be an unmarried domestic maid from a Myanmar, who is uninsured and now faces immediate cancellation of her work permit, loss of her job and immediate deportation for violating the immigration requirement that she is not to become pregnant?
ETHICAL VIOLATIONS(5) • If the doctor in any of the 3 latter scenarios determine that it is alright to set aside the requirement for intensive care and instead offer comfort care • What legal/ethical principle(s) is/are violated if at all ?
LEGAL AND PROFESSIONAL FRAMEWORK What are the Singaporean laws and guidelines if any that authorise the doctor to intervene in this manner ? protect the doctor from criminal and civil liability ? protect the interests of the parents in such a situation?
AUTHORITY FOR THE DOCTOR TO INTERVENE IN THIS MANNER Children and Young Persons Act (CYPA), 1949. …strikes a balance between family authority ….and the protection …by the State. 4. For the purposes of this Act, a child or young person is in need of care or protection if…. ( c ) the parent or guardian of the child or young person — (i) is unable or has neglected to provide adequate food, clothing, medical aid, lodging, care or other necessities of life for the child or young person; ( e ) the child or young person needs to be examined, investigated or treated for the purpose of restoring or preserving his health or development and his parent or guardian neglects or refuses to have him so examined, investigated or treated;
PROTECTION OF THE DOCTOR FROM CRIMINAL CHARGES Children and Young Persons Act (CYPA), 1949. 3 ( b ) in all matters relating to the administration or application of this Act, the welfare and best interests of the child or young person shall be the first and paramount consideration s92, Penal Code Nothing is an offence by reason of any harm which it may cause to a person forwhose benefit if it is done in good faith, even without that person’s consent…if thecircumstances are such that it is impossible for that person to signify consent or if that person is incapable of giving consent, and has no guardian or other person inlawful charge of him from who it is possible to obtain consent in time for the thing to be done with benefit…
PROTECTION OF THE INTERESTS OF THE PARENTS IN SUCH A SITUATION Children and Young Persons Act (CYPA), 1949. 3A. The following principles apply for the purposes of this Act: (a) the parents or guardian of a child or young person are primarily responsible for the care and welfare of the child or young person and they should discharge their responsibilities to promote the welfare of the child or young person. (Revised) Singapore Medical Council-Ethical Code and Guidelines (2016). C8. Caring for Minors (persons below age of 21) You must together with parents or legal guardians …… make decisions based on their best interests. • • If you have reasonable grounds that minors under your care…… abuse, neglect….. take necessary steps….. to protect the minors Common Law
SEEKING CUSTODY If its not urgent • Through the Protector ( Director of Social Welfare, MCYS), supported by the completed CYP Form If its urgent, • then through Hospital’s legal counsel, make an originating summons to the Duty Judge. If its an emergency • and delay will be detrimental, then doctor can take over custody and manage, until authority is received. (Common Law, CYPA, SMC Ethical Code)
Please note that the references to the law are to illustrate legal principles and not to be seen as legal advice
The following presentation is taken from the LCPC Symposium 2016: When Caring Never Stops – Meeting the Needs of Vulnerable Babies
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