The principle of nonmaleficence obligates health care providers to avoid directly causing harm to a patient. Specifically, the plan of care must avoid causing intentional harm. Using the previous example of a neonate in multisystem decline, the NICU team would need to evaluate the continuing use of aggressive therapies with a neonate who is physiologically progressing through the dying process. The plan of care should not involve measures directly intended to cause the neonate’s death, nor should the care plan cause harm without any direct benefit.

The principle of respect for autonomy emphasizes the right of an individual to make decisions for himself or herself. In health care, this principle is reflected in both the right to make decisions about a treatment plan as well as the right to refuse treatment. When an adult is the patient, the health care team seeks permission for treatment by means of informed consent. True informed consent is an actual process that involves more than obtaining a signature on a form or legal document. During the informed consent process, the patient should be provided with accurate, sufficient, and understandable information. The patient can then weigh the pros and cons of the proposed treatment options and, after adequate consideration, the patient can express an informed decision regarding his or her preferences.

In the NICU, parents serve as the legal surrogate decision makers for their neonate. NICU staff can assist parents in their decision-making role by keeping them well informed of the neonate’s condition and by objectively presenting treatment options. Parents’ preferences for care must be reassessed as the neonate’s condition warrants, because their preferences may change in either direction. For example, parents who expressed a desire for very aggressive treatment may later decide that deceleration of care may be in the infant’s best interest. Other parents may decide to continue aggressive care as planned, even though a grim prognosis is present. Regardless, in order for parents to act in their infant’s best interest, they need to be kept informed of all options as well as the likely outcomes of the options.

The principle of justice focuses on the fair distribution of the benefits, risks, and costs among members of society in relation to health care needs. In the NICU, questions of justice frequently arise. For example, two mothers are about to give birth to neonates who will require care in the NICU. The births will occur within an hour of each other. One neonate is extremely premature and will have a less than 20% chance of survival. The other neonate will have a 75% chance of survival. If the neonate with only a 20% chance of survival is born first, should he or she occupy the last available NICU bed or should that bed be reserved for the more viable neonate?

Questions of justice are difficult to resolve at the bedside. Yet pursuing these questions is an important step in achieving balance in health care. Furthermore, moving toward examining justice from a societal perspective provides an opportunity to develop and refine health policy that will assist in refining hospital policies and further translate back to the bedside.

Three of the theories commonly referenced in bioethics are Kantianism, utilitarianism, and liberal individualism. Whereas these theories can assist nurses in examining ethical issues broadly, they do not provide direct guidance for resolving issues at the bedside.

Liberal individualism addresses the rights, both positive and negative, that individuals in our society possess. A positive right requires someone to do something for another individual, such as a health care provider’s duty to treat those in need of immediate care. A negative right keeps individuals from being directly harmed by others. For example, an individual requests that no experimental treatments be performed on him. Without his or her explicit consent, his right cannot be overridden.

Health care providers can begin by summarizing the neonate’s diagnosis and prognosis. The treatment plan, along with the benefits and burdens, would also be discussed.

In the NICU, the health care providers would obtain the parents’ preferences for their neonate’s treatment plan. It would be important to ask the parents what their goals are for the infant. In light of the current and/or proposed treatment plan, the NICU team should also ask parents how they view the benefits and burdens for their infant. It is important to elicit parental preferences as well as any other concerns the parents may have.

This component of the model provides an opportunity to examine the quality of life from the perspective of the health care team and to relate that to the stated parental preferences. This may require additional conversation with the parents to ensure correct interpretation of their values by the NICU team.

At times the NICU nurse may feel torn between support for the parents and support for the health care team. This can occur when the health care team advocates one plan of care and the parents disagree with the team’s recommendation. For example, the NICU team may recognize that the neonate is in multiorgan system failure and that death is imminent, yet the parents continue to request that aggressive medical intervention continue. The nurse has an obligation to support the team and the parents while ensuring that the infant’s best interests are being met. This is where ethical dilemmas arise, and the nurse may find it helpful to seek ethical consultation.