Parental autonomy and ethical challenges in artificial placenta trials: addressing parental disagreements across phases of participation.

Artificial placentas (APs) are technologies developed to mimic the functioning of the human placenta to support extremely preterm infants in an artificial environment until the lungs are developed enough to support intensive care. AP trials will likely consist of two phases: the delivery into AP, which requires a C-section on the pregnant person, and the AP trial, which only involves the infant. This poses a unique challenge to the principle of respect for autonomy: What if parents disagree on trial participation? In the first phase, the pregnant person has the right to make the final decision as they are the one undergoing a C-section, but in the second phase, parents have equal rights. We identified three solutions. First, to only engage with the pregnant person. Although this is an actionable solution that respects the pregnant person's autonomy, it undermines the co-parent's autonomy. Second, to only enrol agreeing parents. This is again an actionable solution that superficially acknowledges the role of both parents, but it undermines the pregnant person's autonomy. We proposed a midway: Clinicians should engage both parents and strive for consensus. If consensus is not reached, then they should follow the pregnant person's decision. However, it must be clear from the beginning that once the infant is in the AP, for every other medical decision, both parents have equal rights and for entrenched disagreements they should resort to court. This has the advantage of providing an actionable solution while truly acknowledging the role and autonomy of both parents.