An ethical framework for antenatal counselling at the threshold of viability

Dr Andrew Hutchinson1

1Grantley Stable Neonatal Unit, Royal Brisbane and Women’s Hospital, Herston, Australia, 2University of Queensland, Faculty of Medicine, Herston, Australia, 3Department of Paediatrics, Mackay Base Hospital, Mackay, Australia

Extreme prematurity presents a number of challenges for health systems, clinicians and families. While advances in neonatal and perinatal medicine have increased the survival of babies who are born below 26 weeks gestational age, substantial morbidity remains prevalent in this population. In Australia, there is general consensus that the threshold of viability for premature infants exists between 23 weeks and 26 weeks gestational age. Life sustaining interventions for babies who are born prematurely are generally not recommended below 23 weeks gestational age and universally recommended above 26 weeks gestational age. At the threshold of viability, health professionals counsel parents and facilitate informed decision-making prior to delivery regarding the provision of life sustaining interventions or palliative care. Counselling involves a family-centred approach that explores parental values alongside education about prematurity and the risks of morbidity, disability and death. International studies suggest that there is widespread variation in antenatal counselling practices and that parental involvement in the decision-making process is inconsistent. Improving outcome data for survival, morbidity and disability dominates discussion in the academic literature around determination of the best interests of periviable infants and moral obligations to initiate life-sustaining interventions. This paradigm influences the dynamics of antenatal counselling and challenges the moral and legal role of parents in determining best interests and reaching informed decisions. A literature review has identified key social and ethical considerations for antenatal counselling at the threshold of viability that support the formulation of an ethical framework guided by principlism and discourse ethics. Fundamental principles include beneficence, respect for autonomy, partnership and trust. An ethical framework will provide a foundation for clinician counselling practices that supports collaborative, informed decision making at the threshold of viability in the best interests of infants and their families.


Andrew Hutchinson is an advanced trainee in general paediatrics and neonatal / perinatal medicine with the Royal Australasian College of Physicians. He is completing a masters of public health and health management through the University of New South Wales involving the study of ethics and law in public health. He has a special interest in antenatal counselling for extreme prematurity including the dynamics of communication with parents.

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