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Artificial placentas (APs) are technologies that mimic the human placenta to treat extremely preterm infants. Being an invasive and risky technology, it will raise important ethical questions for human trials. Hence, in this Topic Piece we provide a blueprint of further issues to investigate. First, counselling will have the double role of providing trial information as well as (non) treatment counselling. This requires extra training and the development of ad hoc decision aids to support counselling and parents' decision-making. Second, more stakeholder involvement is needed. Direct stakeholders, such as parents, clinicians, and researchers, can help develop the decision aids and provide insight on potentially overlooked issues. Society should also be involved to determine whether AP trials and implementation should be subsidized, and the ethical implications of not subsidizing. Third, a proper cost-benefit analysis should be conducted to determine the exact cost of the technology. [ABSTRACT FROM AUTHOR]

Objective: To investigate how to protect participants in the artificial womb technology (AWT) human trials. Method: We compared randomized controlled trials and single arm trials to understand which trial design best balances the interests of science and participants. We also compared AWT trials with comparable settings to understand how to protect participants. Results: Randomized trials might fail in reaching a sizeable sample, which could pointlessly expose participants to risks. Furthermore, parents who choose to participate in the trial might expect to receive AWT. Failed expectations might distress parents and hinder the therapeutic relationship. The trial is divided into two steps. First, delivery into AWT involves two participants: the mother and the fetus. As AWT requires a C‐section, the procedure cannot be carried out without the mother's consent regardless of fetal benefit. Treatment in AWT, involves one participant: the infant. As for any other invasive intervention, the AWT trial should be suspended if harmful. Conclusions: A single arm trial could prevent some of the methodological and ethical challenges of the randomized trials. Moreover, better decisional tools should be developed to help parents decide whether to participate in the AWT trial. For example, using visual aids or showing the AWT. Key points: What's already known about this topic? The first human trial of artificial womb technology (AWT) for preterm infants will commence soonThe AWT trial will involve vulnerable participants (fetuses, infants, and pregnant persons)Balancing the interests of science and participants could be challenging in this trial What does this study add? An in‐depth analysis of the best trial design to balance the interests of science with the protection of participantsClear identification of the participants involved in the two different steps of the trial (delivery into AWT, and treatment in AWT)Concrete suggestions on how to protect participants, improve decision‐making, and empower women's autonomy [ABSTRACT FROM AUTHOR]

Maternal fetal surgery (MFS) trials have the potential to substantially increase the survival and quality of life of fetuses with life-threatening conditions, but they also entail relevant and yet overlooked fair access challenges. In this topic piece, we will present the fair access concerns in MFS trials/practice and their ethical ramifications as well as some possible ways to address them.The most obvious challenge is cost. Although the cost of the surgery itself is generally covered, costs are high for participants, including commute or housing near the hospital. This might hinder participations of parents from lower economic status. Strict eligibility criteria aimed at protecting participants further limit accessibility. These issues further affect the scientific validity of the trial. For example, the above-mentioned issues contribute to difficulties in recruitment which already lead to MFS trials delays and cancellations. They also contributed to homogeneous samples that are difficult to generalize. Hence, it is important that researcher first acknowledge the existence of fair access issues beyond those related to the cost of the surgery itself and that these issues affect participants’ right to fair access to the trial benefits as well as the scientific validity of the trial. Second, it is important that researchers actively try to foresee and reduce these issues. [ABSTRACT FROM AUTHOR]

The article discusses how to make (non)treatment decisions for preterm infants born in the gray zone. Topics include proposal, "postponed withholding" (PPWH), consists of immediate treatment at birth, which is regarded within PPWH as a non-decision, and postponing the decision to continue or withdraw further treatment by a week.

Therefore, it is important that guidelines using GA thresholds specify that exceptions should be considered at any GA, based on other prognostic factors and parents' wishes. However, some ethicists have criticised GA thresholds as clinically and ethically inappropriate and proposed an individualised decision-making process based on prognosis.[2] Between September 2019 and October 2020, we conducted a nationwide study to understand the ethical reasons that guided Belgian neonatologists when they made decisions about whether to resuscitate infants born in EPT. Abbreviations EPT infants, extremely preterm infants GA gestational age NICU neonatal intensive care unit Extremely preterm (EPT) infants are born below 28 weeks of gestational age (GA).[1] They generally need resuscitation at birth, but deciding whether to provide this can be difficult.[1] There is considerable clinical uncertainty on treatment outcomes, which raises ethical questions about whether we should we prioritise quantity or quality of life?. [Extracted from the article]

The article focuses on several conceptual issues linked to proposals to use artificial womb technologies (AWT) as an alternative to healthy pregnancies. Topics discussed include the risks of AWT and the technical unfeasibility of ectogestation, use of AWT for healthy pregnancies to increase female productivity and thus enhance female competitiveness on the job market and women's rights.

The authors discuss the article "Ethical Responsibilities for Companies that Process Personal Data" by M. S. McCoy and colleagues which proposed three substantive principles that should underlie corporations' treatment of data. They discuss data over-extraction and its consequences, dignity as a substantive principle, and direct attacks on data subjects' dignity.

CONTEXT: Whether to resuscitate extremely premature infants (EPIs) is a clinically and ethically difficult decision to make. Indications and practices vary greatly across different countries and institutions, which suggests that resuscitation decisions may be influenced more by the attitudes of the individual treating physicians. Hence, gaining in-depth insight into physicians' attitudes improves our understanding of decision-making regarding resuscitation of EPIs. OBJECTIVE: To better understand physicians' attitudes toward resuscitation of EPIs and factors that influence their attitudes through a systematic review of the empirical literature. DATA SOURCES: Medline, Embase, Web of Science, and Scopus. STUDY SELECTION: We selected English-language articles in which researchers report on empirical studies of physicians' attitudes toward resuscitation of EPIs. DATA EXTRACTION: The articles were repeatedly read, themes were identified, and data were tabulated, compared, and analyzed descriptively. RESULTS: Thirty-four articles were included. In general, physicians were more willing to resuscitate, to accept parents' resuscitation requests, and to refuse parents' nonresuscitation requests as gestational age (GA) increased. However, attitudes vary greatly for infants at GA 23 to 24 weeks, known as the gray zone. Although GA is the primary factor that influences physicians' attitudes, a complex interplay of patient- and non--patient-related factors also influences their attitudes. LIMITATIONS: Analysis of English-only articles may limit generalizability of the results. In addition, authors of only 1 study used a qualitative approach, which may have led to a biased reductionist approach to understanding physicians' attitudes. CONCLUSIONS: Although correlations between GA and attitudes emerged, the results suggested a more complex interplay of factors influencing such attitudes. [ABSTRACT FROM AUTHOR]

Objectives: To investigate what empirical studies report on the perceptions of community-dwelling LGBT adults regarding sexuality and sexual expression in residential aged care (RAC), and how their sexuality should be addressed in RAC. Methods: Relevant papers were identified through electronic searches in databases; and by reference tracking and citation tracking. Data were extracted using a standardized data extraction form and were compared, related, and synthesized using thematic analyses. We evaluated the methodological quality of the studies. Results: Eighteen articles were identified. Three major topics emerged regarding sexuality in RAC: (1) factors affecting LGBT people's perceptions, subdivided into (a) discrimination, (b) loss of sexual identity, (c) failure to acknowledge the same-sex partner, and (d) lack of privacy; (2) LGBT-specific RAC facilities; and (3) characteristics of LGBT friendly RAC facilities and caregivers. Conclusions: LGBT people have clear perceptions about how sexuality and sexual expression is or should be managed in RAC. Despite the general increase in acceptance of sexual minorities, many community-dwelling LGBT people believe older LGBT residents are discriminated against because of their sexual orientation or gender identity. Taking into account these opinions is crucial for increasing accessibility of RAC to LGBT people and to ensure the quality of the provided care. [ABSTRACT FROM AUTHOR]

Objectives: To better understand how nurses experience and react to intimate and sexual expressions of nursing home residents. Background: Although many nursing home residents continue to desire intimacy and sexual expression, they commonly perceive negative attitudes of nursing staff towards them as a major barrier to their sexual well‐being. To eliminate this barrier, it is crucial to gain a more in‐depth understanding of nurses' personal experiences and reactions towards intimacy and sexuality in aged care. Design: Our study used a qualitative design, rooted in grounded theory. Methods: Semi‐structured interviews with 15 nurses between 34 and 59 years of age were conducted. Participating nurses were recruited from seven different nursing homes in Flanders, Belgium. We used the Qualitative Analysis Guide of Leuven (QUAGOL) for data analysis. We followed the COREQ guidelines to ensure rigour in our study. Results: Nurses experienced and dealt with intimate and sexual expressions of residents in an individual way, which was focused on setting and respecting their own sexual boundaries and those of residents and family members. Depending on their comfort level with residents' expressions, nurses responded in three ways: active facilitation, tolerance and termination. Nurses' responses depended on contextual factors, including their personal experiences with sexuality, the nature of their relationship with the residents involved, the presence of dementia and the organisational culture of the facility. Conclusions: Nurses face a wide range of experiences and emotions when confronted with residents' expressions of sexuality and intimacy. A supportive approach is needed to guide nurses in dealing with these highly sensitive situations. This approach can be promoted at the institutional level through continuous educational programmes. Relevance to clinical practice: This study advocates a contextual and interpretative ethical approach to sexuality in older adults, taking as starting point nurses' own vulnerability and that of residents and relatives. [ABSTRACT FROM AUTHOR]

REFERENCES 1 Sriraman S, Demirhan M, Golombek S. Beyond the numbers: unpacking the complexity of resuscitation thresholds in periviable infants. We read with interest Sriraman et al's (2023)[1] response to our article 'Resuscitation thresholds were seen as guidance by Belgian neonatologists and other relevant factors were included in decision-making'.[2] We appreciate that other institutions use an integrative approach to resuscitation decisions for extremely premature infants, one that takes into proper account other prognostic factors as well as parents' opinion. [Extracted from the article]

This systematic review aims at presenting the ethical debate on the artificial placenta (AP) by identifying, distinguishing, and organizing the different ethical arguments described in the literature. Articles were selected based on predefined inclusion criteria: discussing ethical arguments, on AP, written in English. QUAGOL methodology was used for analysis. Forty-five articles were included. We identified three themes. First, foundational-ethical issues. There is disagreement on whether the AP subject should be considered an infant or a new moral entity. While physiologically it stays in the fetus, it sits outside the womb. Second, reproductive ethics issues. Few authors believed that the AP would increase reproductive choices. The majority warned that the AP could limit reproductive choices by creating pressure to use it in healthy pregnancies or as an alternative to abortion. Third, research ethics issues. Publications mostly focused on the selection of the in-human trial participants. We concluded that AP ethical literature focuses mostly on the potential use of AP as an alternative to abortion or healthy pregnancies rather than on its intended use as a treatment after extremely premature birth. Therefore, we conclude that the current ethical literature on AP is imbalanced: it leans more toward science fiction than actual clinical and technological reality., (© 2024 John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared.

Objective: Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions., Methods: We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven., Results: We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician., Conclusion: Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Cavolo, Dierckx de Casterlé, Naulaers and Gastmans.)

Competing Interests: Competing interests: None declared.

Objective: To present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts., Design: We conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation., Analysis: After repeated reading of articles, we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed., Results: Forty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision., Conclusions: The included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents' decision should be over-ridden when in contrast with the EPI's best interest., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)