Postponed Withholding: An Ethical Tool for Health Care Personnel to Empower Parents

We are grateful for our peers’ comments on our target article (Syltern et al. 2022), and welcome their valuable suggestions and challenges. A special thanks to Tissington for sharing reflections based on his personal experience, providing invaluable insight (Tissington 2022). Reading the comments, it strikes us that there is a general agreement about shared decision-making as the model of choice when faced with ethical uncertainty about whether to start, and continue, life support in the gray zone of periviability. To support parents faced with the tragic choice of letting their baby die, or to expose their baby to the burden of NICU treatment, inevitably involving hundreds of painful procedures and followed by uncertain outcome, we must act wisely. We do not believe that our framework will make the decision easy, maybe not even easier. Our aim is to foster ethically sound decision-making. In the comments, we found elements that can enrich our model, as well as substantial misinterpretations. We appreciate the opportunity to provide further clarification by responding to some of the criticisms, and to show why postponed withholding is more than a euphemism. Several commentators mentioned the need to improve shared decision-making processes, and the aim of the postponed withholding (PPWH) approach is to provide clearer ethical guidance to health care personnel (HCP). Any framework, ours included, can be misused in the absence of good will. As empathetically pointed out by Kaempf, the ultimate goal of our framework is in line with the quote from Philippa Foot: an “attempt to connect good reasoning to goodness” (Kaempf and Dirksen 2022). However, reasoning is not enough. In order to help parents in the midst of despair, we need to truly see and pay attention to their individual needs. As the philosopher Iris Murdoch pointed out: “I can only choose within the world I can see” (Murdoch 1971). She puts forward the need for just and loving attention, aiming for an unselfish, unbiased and world-disclosing perception. This is essential to our framework: most parents do not have any fixed values that are ready to be applied on situations like these. They will have to articulate those values in a close dialogue with HCP, in order to provide what the philosopher Charles Taylor has called “a horizon of significance,” under which self-choice becomes important. This is why we believe that “informed nondissent,” as proposed by Kon may be problematic, if not accompanied by sufficient decisional space. It does not per se guide HCP to empower parents to participate in shared decision-making (Kon and Kon 2022). Actually, PPWH is set up to be an ethically balanced “informed nondissent,” aiming to assure that parents are sufficiently empowered before any irreversible decision is made. Among others, De Proost and Kukora claim that our model discounts parents’ wishes in the antenatal encounter, and thus undermines trust (De Proost et al. 2022; Kukora et al. 2022). Our model does support parents who want to forego life support at birth. However, since time is essential to the articulation of wishes and values in the midst of a shock, we must avoid rushing decisions. Seeing life support at birth as a non-decision gives room for an open process. To achieve the goal of empowering parents, we advocate for strengthening the prenatal counseling process by starting a continuous process of building partnership