A quality of life quandary: a framework for navigating parental refusal of treatment for co-morbidities in infants with underlying medical conditions

Parental refusal of a recommended treatment is not an uncommon scenario in the neonatal intensive care unit. These refusals may be based upon the parents' perceptions of their child's projected quality of life. The inherent subjectivity of quality of life assessments, however, can exacerbate disagreement between parents and healthcare providers. We present a case of parental refusal of surgical intervention for necrotizing enterocolitis in an infant with Bartter syndrome and develop an ethical framework in which to consider the appropriateness of parental refusal based upon an infant's projected quality of life.

[Placebo surgery: surprises and ethical questions]

Placebo has a well-known therapeutic potential and this explains why placebo-controlled trials are considered necessary for showing the efficacy (and to a lesser extent the safety) of a new drug treatment. However, there are clear examples of a potent surgical placebo-effect in several pathological fields (cardiology, osteoarthropathy, slipped disk, post-traumatic lesions, abdominal adhesions, Parkinson's disease). The efficacy of the placebo surgery would suggest the advisability of placebo-controlled studies also for some surgical treatments. This type of trials, however, raises a number of reservations and ethical questions. In particular, it is necessary to consider the possible unethical nature of placebo surgery as against the unethical nature of surgical operations lacking any evidence of "specific" efficacy (i.e. being better than placebo).