Ethical Considerations in the Neonatal Intensive Care Unit

Lisa J. Sundean, RN, MSN, MHA; Jacqueline M. McGrath, PhD, RN, FNAP, FAAN


NAINR. 2013;13(3):117-120. 

In This Article


Nonmaleficence means non-harming or inflicting the least harm possible to reach a beneficial outcome.[4] Harm and its effects are considerations and part of the ethical decision-making process in the NICU. Short-term and long-term harm, though unintentional, often accompany life-saving treatment in the NICU.[1] Consider again the example of the infant with PPHN who is placed on ECMO treatment. Although ECMO can provide life-saving treatment for the neonate, this high-tech, high-touch treatment has high potential for harm from infection, fluid and electrolyte imbalances. Weighing the ethical principles of nonmaleficence and beneficence presents the question: What is in the best interest of the neonate to provide the best possible outcome with the least amount of harm? The potential iatrogenic effects of the NICU must always be weighed against the potential best outcomes.

The principle of nonmaleficence is also a consideration when treatment is futile. In this case, prolonging treatment is a violation of the principle of nonmaleficence. Conversely, the withdrawal of futile treatment and the institution of palliative care align with the principle of nonmaleficence.[2] Providers must question the potential harm and benefits of technology in cases of extremely premature and critically ill neonates whose prognoses are poor. Use of technology in these cases often inflicts further pain and suffering and will not lead to positive benefits. Consider the infant born with Trisomy 18, a genetic disorder considered incompatible with life. The principle of nonmaleficence in combination with the principle of beneficence guides clinicians in suggesting a palliative plan of care for the baby. This treatment option minimizes harm to the infant and prevents prolongation of futile treatment. However, it is also important to respect and support the wishes of the family who requests continuation of interventions. Weighing the needs of the family is sometimes the most challenging aspect of these types of situations.

Further, providers must consider the potential for harm from iatrogenic effects of treatment, particularly with long-term treatment, and must commit to reducing medical errors and harmful events.[1] The focus of reports from the Institute of Medicine regarding health care quality aim to reduce preventable harm to patients and improve favorable outcomes.[6] Considering the vulnerability of infants in the NICU, nurses and physicians must commit to reducing and limiting harm when providing care. This is especially true in the technology-intensive NICU environment.