With the Andrew Wakefield MMR and autism scandal, and the subsequent rise of the anti-vaccination movement, today's patients can now be seen as sceptical consumers keen to assert their autonomy, and no longer passive recipients of medical paternalism.
Another aspect of hitherto accepted medical care that is coming under scrutiny is vitamin K prophylaxis for the newborn. First described in 1894, vitamin K deficiency bleeding (VKDB), or haemorrhagic disease of the newborn, is an acquired coagulopathy in infants characterised by an inability to activate the vitamin K-dependent coagulation factors (II, VII, IX, and X), due to a lack of vitamin K (Schulte et al, 2014).
By 1944, it had been demonstrated that prophylactic vitamin K given at birth reduced VKDB-associated death more than fivefold in the first 2 weeks of life (Schulte et al, 2014); a Cochrane Review found that a single dose of intramuscular vitamin K was effective in preventing VKDB (Puckett and Offringa, 2000); and guidelines from the National Institute for Health and Care Excellence (NICE) (2015) state that parents should be offered vitamin K prophylaxis for their babies, best administered as a single intramuscular dose of 1 mg.
Despite the effectiveness of vitamin K prophylaxis, Schulte et al (2014) reported that parental refusal was increasingly common, with the authors encountering seven infants over an 8-month period with confirmed vitamin K deficiency, none of whom had received vitamin K at birth.
To what extent might midwives influence parental decisions? In a study from New Zealand, Gosai et al (2014) reported that while 100% of medical staff felt that all babies should receive vitamin K, only 55% of midwives did so. The authors speculated that more midwives might have safety concerns and doubts over future health consequences.
Another possibility is that midwives simply have other priorities. For example, according to evidence taken from student midwives in a study by the Royal College of Midwives (RCM), one said:
‘Delayed cord clamping and skin-to-skin are big at my Trust too, including with caesarean sections, they try where possible to delay weighing and giving vitamin K and get baby to mum to have skin-to-skin as quickly as possible!’
The report also found that:
‘In the postnatal period, the priorities for midwives were seen as breastfeeding (it was notable that there was little mention of safe bottle feeding), mental health and SIDS prevention.’
In another New Zealand study of 15 families (Miller et al, 2016), when asked why parents opted out of newborn vitamin K prophylaxis, reasons fell into three categories: parental beliefs; concerns over pain and potential side-effects; and the influence of family, friends media and health professionals. Miller et al (2016) referred to a possible link between vitamin K and immunisation, with those declining newborn prophylaxis also more likely to subsequently decline immunisation.
In an attempt to resolve these competing tensions, Kerruish et al (2017) adopted an ethical analysis of the issue, accepting that the phrase ‘best interest’ in the context of the infant can be difficult to define, and may be perceived differently by parents and health professionals. Instead, Kerruish et al (2017) cited ethicists who argue that:
‘Instead the focus should be on harm, with parents only overruled when their decision would cross a threshold level of harm. Or put a different way, parental decisions should be accepted unless the child is likely to suffer significant harm.’
A space that accepts sub-optimal parental decisions is called the ‘zone of parental discretion’ (Kerruish et al, 2017: 9).
The increasing assertions of parental/patient autonomy can be expected to lead to lively discussion (and, perhaps, confrontation) on what constitutes good medical practice.