Neonatal intensive care units (NICUs) are a priority implementation area for genomic medicine. Rapid genomic testing in the NICU is expected to be genomic medicine’s ‘critical application’, providing such clear benefits that it drives the adoption of genomics more broadly. Studies from multiple centres worldwide have now demonstrated the clinical utility and cost-effectiveness of rapid genomic sequencing in this setting, paving the way for widespread implementation. However, the introduction of this potentially powerful tool for predicting future impairment in the NICU also raises profound ethical challenges. Developing models of good practice that incorporate the identification, exploration and analysis of ethical issues will be critical for successful implementation. In this paper, we analyse three such issues: 1) the value and meaning of gaining consent to a complex test in a stressful, emotionally-charged environment; 2) the effect of rapid diagnosis on parent-child bonding and its implications for medical and family decisions, particularly in relation to treatment limitation; and 3) distributive justice - whether the substantial cost and diversion of resources to deliver rapid genomic testing in the NICU can be justified
