Neonatal palliative care (NPC) is an integrated and holistic approach that is an integral part of the contemporary neonatal treatment delivery paradigm. It is the highest fulfillment of the notion of beneficence (doing or creating 'good') that has otherwise been neglected/underestimated by the focus of modern medicine on technology and instrumental treatments by its commitment to alleviating patient pain and quality of life. For decades, the Double-Effect Doctrine (DDE) has been used to consider and address a range of ethically questionable circumstances, often at the end of life, including euthanasia, termination of pregnancy to save maternal life, and morally justified warfare. The theory has continued to be mired in controversy as ethicists, legal scholars, theologians, and philosophers discuss the abstract concepts of moral reasoning, purpose, foresight, and other underlying moral theories. In this paper, the moral theory of DDE is discussed in its clinical application to the ethical decision-making process in neonatal palliative and end-of-life treatment, specifically 1) the administration of opioids as required for symptom control and 2) the use of palliative sedation for intractable symptom care.

In thermodynamic theory, free energy (i.e., available energy) is the concept facilitating the combined applications of the theory’s two fundamental laws, the first and the second laws of thermodynamics. The critical step was taken by Kelvin, then by Helmholtz and Gibbs— that in natural processes, free energy dissipates spontaneously. With the formulation of the second law of entropy growth, this may be referred to as the dissymmetry proposition manifested in the spontaneous increase of system/environment-entropy towards equilibrium. Because of Kelvin’s pre-entropy-law formulation of free energy, our concept of free energy is still defined, energy-centrally, as body’s internal energy or enthalpy, subtracted by energy that is not available within a framework on the premise of primacy of energy, in which free energy dissipates spontaneously and universally. This primacy of energy is called into question because the driving force to cause a system’s change is the purview of the second law. This paper makes a case for an engineering thermodynamics framework, instead, to be based on the premise of the primacy of dissymmetry over free energy. With Gibbsian thermodynamics undergirded with dissymmetry proposition and engineering thermodynamics with the dissymmetry premise, the two branches of thermodynamics are unified to become classical thermodynamics.